Stories in Medicine

Restoring faith

2011-12-31T07:49:00.000-06:00

After my post yesterday, where I rant and raved about deadbeat coward dads who beat little kids senseless, I think the Lord knew I needed some therapy.

So, the first 3 patients in my schedule were it. Now, keep in mind that apart from a new last minute changes, some of my patients, especially those coming in for complete physicals have been scheduled months in advance.

This morning, one after another, I got to do physicals on relatively healthy, young (in their 30s to 40s) wonderful men. They had jobs or ran their own businesses. They took care of their health, eating sensibly and exercising. They were married and faithful to their wives. They were loving, protecting and doting fathers. I could not help but tell them that I appreciated their stepping up to the plate and fulfilling their role as men, husbands and fathers. One of them gave me a quizzed look. He probably wondered why I was making so much of what he just did as a matter of fact. If only he knew...

The 90s

2011-12-31T07:42:00.000-06:00

Yesterday was a strange day. Med-Peds makes for some interesting contrasts. I went in to see a 93 year old. She still drives, lives alone and is quite healthy, other than some arthritis. I once joked with her saying "I hope that when I'm 90, I'm as healthy as you and still practicing medicine. She came back with "And I hope I'm still your patient."

The next patient was 2. He was, well... 2... running around, playing and talking.

The next patient was 96. He came with his daughter. Apart from swelling in his lower legs, he was doing quite well, thank you.

The next patient was another 2 year old, a girl, this time.

Thank you, dear patients, for bringing joy and hope to my life.

To those of you who still live in the past (when people who died in their 70s had 'lived a long and good life', it is time to update: we CAN live into our 90s and enjoy a good quality of life.

Needed: a few good men

2011-12-29T19:47:00.000-06:00

If you're not in the mood to hear me rant and rave, don't read this post...

Nothing tears your heart up like child abuse does. When a child feels guilty for turning in his father or step-father that is abusing him and his younger siblings, you want to grab him by the shoulders, shake him and tell him that he's the victim, the abused. It always amazes me that despite being beaten badly, thrown across a room, physically abused and made to feel like trash (wish you were never born, you're not my son), a child still misses his dad.

Oh, for a few good men. Men who earn a living and provide for their family. Men who protect their children rather than beat the living daylights out of them. Men whose children feel they are big and strong and inspire confidence and a feeling of security, rather than make them cower in fear. Men who inspire their children to run home to them when they are afraid, rather than their children being afraid to go home to them.

I thank God for the many fathers in my practice who love their kids. I even appreciate the ones that hover over me when I examine their child, or yell at me, frightened and helpless, to do something, when their child is sick or in pain. These are men.

Not the cowards who use their strength to beat up a little one, who hurt and dissappoint.

And through all the fear, bruises and being put down, these children still miss their dad and want to make them proud. Go figure.

Be vigilant. Stamp out child abuse. Join me in affirming and assuring children that if they are being hurt, they can talk to you and you will do something about it. Show these little ones what adults can really do. Speak positive things, affirm, praise, reassure and cheer up a child.

ER over Christmas

2011-12-29T19:34:00.000-06:00

I love my family! From December 1 to 15, I got to go home. I saw my Mom, brother, his wife and my nephew. We did not do anything special... just hung out. It was great to eat home-cooked food, and just to spend time with my family. When we're together as my mother often says, it's birthday, anniversary, Christmas, New Year...every special day. I agree completely.

So I returned to good 'ol Marshfield refreshed and ready for action. I volunteered to work extra shifts in the the ER over the Christmas holiday, Saturday through Monday. Here's a sample:

Cow kicked man in thigh. Man got mad, kicked cow back...sprained ankle.

Sewed up the foot of a 3 year old that stepped on a Christmas toy. Despite numbing up the area, he cried through the whole thing, even with rubbing gauze on an injured portion of the foot. Oh well, put the stitches in and got out of there.

Finally, I saw Jesus on Christmas. Well, I mean Jesus was an infant with gastroenteritis that I got to see in the ER. Still...

I love my job!

Beware the Vampire Chipmunk!

2011-11-24T12:44:00.000-06:00

It was a normal clinic day. I had to do a well child on a 4-month baby girl. Mom, Dad, brother and sister came with. To keep the other kids occupied, we have learned to give out pictures for them to color. Since I can run late sometimes and families can be in a room for a while, it helps. My patient's 7-year old big sister was doing a great job coloring a picture for me. When we were done with the visit, she proudly handed me the picture. There was a spot of red painted near the mouth of this charming printed picture of a chipmunk. Curious, I asked what that was. She proudly told me:

"That's a vampire chipmunk! That's blood."

And smiled like an angel.

I asked her what she had dressed up as for halloween. She had been a vampire hippie. Of course, the teeth hurt after a while, so she switched to just being a hippie.

:-)

Here's the picture

4-year old philosophy

2011-11-18T12:45:00.024-06:00

Sometimes even little children can teach you the lessons of life. It was a well child visit for little brother of this 4-year old little girl, Charlotte. I love visiting with this family because when I enter into the room, I get greeted enthusiastically and rewarded with the best hugs, nothing held back. Little Charlotte calls me 'Vijay', like we're old pals. (Remember, she's 4). Well, this time she drew me this beautiful picture and wrote a word of wisdom for me. It's fun watching your patients grow as a doctor. I see the entire family and have seen them when they come in for well child visits, illnesses, injuries -- the lot. Charlotte must be just learning to write and like many 4 year olds, she inverts some of her letters.

As I struggled to read what she wrote, I could recognize only one word: 'poop'.

'This should be interesting' I thought.

I asked, "Charlotte, sweetie, this is beautiful! Can you read to me what it says?"

And here's the words of wisdom, one of life's truths. Are you ready?

"Everybody poop and that's the story."

Deep, isn't it?

The stool sample

2011-10-15T12:57:00.000-05:00

One of my 70-something year old patients had an appointment with me. As mostly happens, she came with her husband. As I walked into the room, he looked at me seriously and said, "Doc, I brought in a stool sample." My forehead creased as I tried to figure out what was going to come next. One of the things with being a doctor who sees entire families is that often, you get to address the health concerns of a family member that was only accompanying the family member you are actually scheduled to see. No problem. It comes with the territory. My mind was racing with differential diagnosis: gastroenteritis? Blood in the stool? Diarrhea? Colitis?

And then he handed me the bottle. I didn't get it at first, until I opened the bottle and emptied out the 'sample':

Falling...

2011-10-04T13:18:00.001-05:00

An 80-something was escorted into the room by his wife and son. He was full of jokes.

"Doc! I have something for you!"

"Okay..." I say not knowing what to expect.

"If you fart in church, you'll have to sit in your own pew!"

He breaks out in a mischievous smile as we all laugh.

And then we get down to business. I had seen him before for a complaint of frequent falls. In his 80s, I suspected a gait disturbance, orthostatic hypotension, arthritis, a large prostate (necessitating him having to get up at the odd hours of the night to urinate). I had tried to address each of these, but his symptoms persisted. What was going on?

The falls were getting worse. I had him stand in the room with outstretched hands and his eyes closed, prepared to catch him if he fell. He was to stand that way for 30 seconds. Within 10 seconds he began to sway and fall. I caught him. The test was positive. This test is called the Romberg test and we use it to assess cerebellar function. A chill ran down my spine when the thought came to mind as to what this might be.

I needed an MRI of his head to be sure. I got the study and here is the result below:

The bright white spot in the cerebellum is a cancerous mass. We admitted him to the hospital. Over the next few days in the hospital, he became more confused, sometimes agitated and sometimes somnulent. His wife sat by his side and knit to pass the time.

We discharged him from the hospital to home hospice, anticipating that he would die within months. I fought back the tears as his wife placed 2 little cup mats she had knitted in the hospital into my hands and said,

"Thank you for everything you've done, Doctor. I want you to have these so that you'll remember us."

I am this patient's hospice doctor. I do not think I will ever forget him or his family. The mats are in my office.

Addendum on December 5, 2011....

While out of the country, I received news that this patient died this weekend.

What did you do this weekend?

2011-09-19T13:20:00.013-05:00

An 80-something year old was in for an office visit on a monday morning. He walked without a cane and did not wear glasses. While I was doing my exam, to make conversation, I asked:

"So, Jim [not his real name],what did you do this weekend?"

"Well, Doc, my daughter, son-in-law and me went hunting for bear."

Surprised at this answer from an 80-something year old, I asked,

"So, did you get anything?"

"Oh yeah! We killed two bears!"

"No you didn't" I blurted out before my brain could intercept the words to prevent them coming out of my mouth.

Later that day, I received this picture from him. He took the picture so he is not in it.

The Brothers Mayo and their Institution

2011-07-18T13:49:00.037-05:00

In July, I got to go to Rochester to attend a course in Internal Medicine. It was summer and beautiful. I had never been to Rochester. Rochester, Minnesota is best known for the world-famous Mayo Clinic. All these years, I had read its name in jounals, studies and the popular press. I finally got to see the place for myself.

What impressed me most of all is the vision of the Mayo brothers. Here they are (maybe it's just me, but don't they look like they're made of chocolate?)

The plaque near the statue is shown below:

I have a brother too. I love that neither of them ever wanted to claim credit for themselves, but always spoke humbly of themselves as a team.

The vision of these two surgeons and their father led to an institution that put Rochester on the map and created many notable medical breakthroughs.

Here is the entrance to one of the older buildings called the Plover building. It is named after one of the first physician-scientists that the brothers hired to part of the 'Mayo Clinic'. He went on to win a Nobel prize. The rest of the building is shown below. My lack of skills in photography limit me from doing justice to the beauty of the building.

Here is an elevator in the building. Wow!

The main clinic building is in the next two pictures shown below:

The Brothers Mayo believed in education and also build a medical school:

The moral of this story: vision can accomplish great things.

Camp Angel Summer 2011

2011-07-10T16:55:00.009-05:00

It's summer!

Once again, Angel On My Shoulder (http://angelonmyshoulder.org/) put on its summer camp for kids experiencing cancer through a loved one. Who comes to these camps? Boys and girls, ages 8 through 12. This year, we had 45 camper and 11 counselors. What's so special about these kids? Well, just for samplers, one has a brother with an inoperable brain tumor, 3 of them a mom with lung and brain cancer, 4 more have moms with cancer, several have brothers and sisters with leukemia and a pair had their mom die from cancer just within the last week. Kids deal with these tragedies in different ways. Often the illness casts a deep and dark shadow over their childhood. Here at camp, they can be kids again. The camp was held, as it is most every year, at Camp Luther (http://www.campluther.com/). This is in northern wisconsin just north of Rhinelander and Three Lakes.

I arrived late this year. Clinic was VERY busy and I only got in to camp at about 9:30 pm at night. Camp was rather uneventful from a medical standpoint (the way I like it). I treated some cases of heat exhaustion, abdominal pain and one little girl with whom the dialog went something like this:

"Hi! I'm Dr. Vijay. What's wrong?"

"My tummy hurts and (sniff), I'm homesick!"

On Friday evening when the campers arrive, we have icebreakers (to get everyone to know everyone else). They then report to their camps -- rustic camp sites constructed and named 'The Tower', 'Fort', 'The Ark' and 'Treehouse'. The Camp Luther's website (link above) has pictures of these camp sites.

Once settled in, the campers came back down to the main center for dinner. After dinner, there was a special visit from the Northern Harley Club. These bikers give their time to visit the camp and let the kids oogle and pose on their shiny Harley Davidson motorcycles. Campers went on a scavenger hunt after that, and then headed back to camp for the night.

The next morning before breakfast, campers were out on the court playing 4 Squares and shooting hoops. I learnt to play four squares last year. There is a square divided into four with a player in each sector. The goal of the game is to bounce your ball into another square. There are by-laws like 'chicken feet' and 'black magic' to modify the rules of the game.

4-Squares - black magic and chicken feet

I learnt a new game this year: Ninja. Players stand in a circle and after bowing to each other,

Ninja -- yyyyyaaaah!

strike a Ninja pose. Then each person is sequent has a turn. The player tries to touch another player on the hand or wrist. If they succeed, that player is out. Of course, that player can move their hands out of the way. It is great fun to play and to watch. Here are some pictures.

After breakfast, we headed out to Eagle River for a ride on a Pirate Ship (http://eagleriverpivates.com/). This year, before getting on board, Captain Steve's daughter, gave us all a class on hoola hoop dancing. The kids loved it.

Captain Steve's daughter teaches the Hoola

Can you do the hoola hoop?

We saw the ship come in

Pirates returning from a trip

and climbed aboard for a fun ride on the channel. Our ship was piloted by Captain Steve and his first mate, Steve-O.

Captain Steve and Steve-O steering the ship. Aarrhhh!

While on board, we ate popcorn, drew on white t-shirts which we got to take home,

Drawing on the T-shirts

and saw cool things like this eagle's nest (check out the eagle sitting above it),

Eagle Nest -- can you see the eagle sitting on the branch above?

a giant red chair on the shore near someone's house,

The Giant Red Chair

and a duck and her duckings in a row.

A duck and her ducklings. Ahoy, mateys!

There was swashbuckling sword duels with bubble swords (see picture)

(Bubble) sword play with the Captain

and listened to Pirate songs (like "My name is Roger the Pirate and my favorite letter is R(arrrrrhhh!").

We came back to camp to a barbecue cook out, then spent time in the water, tubing, swimming and doing crafts.

Tubing behind a jet ski. Hold on tight!

Some kids went fishing and I hear, we caught 20-odd bluegill and other fish. Some were as big as my arm (okay, not really). As I do every year, I got my painted rock. This year, I chose a penguin. No, I did not paint it myself. (see picture).

After cleaning up. in the evening, we had dinner and DJ Dan brought out his music system. We had fun dancing

Dance Revolution

, doing the Tonga and seeing how low we could go under the bar (of course, some of the little kids could just walk underneath with no bending needed (see the picture).

How low can you go?

Sunday morning, after more games of Ninja

A final game of Ninjas -- the Masters at work

and 4 squares, campers boarded the bus to go back home.

Time to go back

It was fun. Campers could forget the seriousness, tragedy and pain of home for a while and just be kids. Volunteers (counselors, cooks, fisherman, helpers, doctor, face painters, jet ski-ers) all came and helped out.

We'll be back in Winter for another camp.

See you at camp in winter 2012!

Julia (not her real name)

2011-07-01T20:43:00.029-05:00

I first met Julia when she brought in her newborn son, Caleb for a well child visit. She seemed thrilled with her new baby and doted over him as moms do. During the course of getting a history, I discovered that Julia worked as an exotic dancer. She was not entirely sure who the father of the baby was but thought it was her 'agent'. She told me that she planned to have nothing to do with him.

Over the next few well child visits, Julia seemed to be coming unglued. She complained that the neighbours were teaching Caleb to say vulgar words and that she had caught him saying them (he was about 2 months old at the time). Her speech was rapid and she rambled on not giving enough pause for me to interject a word in sideways.

Julia established care with me since she did not have a doctor. Reviewing her medications, I noted she was on medications for bipolar disorder, ADHD and anti-psychotics. I asked her about her psychiatrist and she told me she saw him regularly.

After several strange phone calls to the nurse line, a social worker was sent to Julia's house. Someone had expressed concern for Caleb's wellbeing, although at every visit, Caleb was gaining weight, meeting development milestones and always looked clean and well cared for.

Caleb was taken away from Julia by the court.

Julia's mental health seemed to worsen. She told me that her psychiatrist and counselor had 'fired' her for noncompliance with treatment and missing scheduled appointments. This was confirmed by a letter to me by the psychiatrist that said very little other than that they would no longer see Julia.

One day, Julia came in claiming that someone had come into her house, cut her hair and stole her ADHD meds. She wanted an early refill on them. I politely told her I would not refill the meds until she either brought in a police report documenting what had happened or showed me proof that she had established with another psychiatrist. She lost her temper and stormed out of the office, after telling me that she no longer wished me to be her or Caleb's doctor anymore.

After being rejected by other physicians with whom she tried to establish care, Julia called my office again and asked for an appointment with me. She mentioned that she was told that until she had taken her medications and was more stable, no-one else would take her on as a patient.

Julia still does not have a psychiatrist. She has not regained custody of Caleb. She continues to have good days and bad days and alternates between being flirtaeous and threatening.

Has the healthcare system failed Julia?

Privacy

2011-06-18T22:53:00.003-05:00

I was chatting with a colleague at a birthday party the other day. This physician said something interesting. His wife added to it. They mentioned how he does not list his telephone number in the phonebook. He tries to avoid going to the grocery store at peak hours. He chided his wife because she bought some tobacco at the checkout counter. She was buying it because someone had suggested putting it around her plants to make them grow better. She wanted to try that out. He was afraid of being recognized and what people might think.

As I finish my second year in practice after residency, I am beginning to understand. Being a doctor is a 'full-time' job. It is however, more than that. One's patients view one as someone with whom they can share their suffering, pain, fears, depression and the medical problems that may be the cause of the result. Often, people are inclined to run a medical problem by you. Family and friends count on you as their go-to person for medical problems. Even if they don't, as a medical profesional, one feels obliged to pitch in and help. Slowly, one's identity in the eyes of many merges with one's profession of being a physician.

As a person, one may want to protect some time 'away' from this identity. As a medical student and resident, I often wanted to be known as a doctor in public so I could help if it was needed. I often wondered why older physicians tended to be more discrete about their identity as doctors. I misinterpreted this as their unwillingness to step up to the plate and help if needed. I now know that this is not true. I have seen doctors quietly come forward and do what needs to be done. I guess I understand now that sometimes a doctor wants to just be a regular person and not feel the weight of being the reliever of suffering or the sympathetic listener or the ...doctor. Most physicians struggle with guilt, as it is, that they are not doing enough for their patients or they are not sympathetic or empathetic enough. So this is difficult to talk about. It is an internal conflict between the desire to be there and make a difference and the need for recharging one's own reserves. I think this is why doctors are private people. My number is still in the phone book.

Cystic fibrosis

2011-06-18T22:38:00.002-05:00

One of our beloved physicians retired. He used to (single-handedly) take care of the cystic fibrosis patients that come to us for their care. After he left, we decided that the kids would be cared for by one of my pediatric colleagues, while I would take over the care of the adults.

I had taken care of CF kids during residency. I thought I knew what I was getting into. I had never been involved with taking care of them as adults.

Cystic fibrosis, for those who do not know, is a genetic disease cause by a mutation in a gene that codes for a chloride transport protein. It manifests as increased, thickened mucus in the lungs, sinusitis, diarrhea (from destruction of the pancreas, so it does not make enough digestive enzymes) and often sterility. Because of its genetics, there are often multiple members of a family with the disease. They need frequent hospitalizations -- at least twice a year -- for intensive antibiotics, chest physical therapy, oxygen therapy and pulmonary therapy.

The first patient I got to care for in the hospital was a pleasant 40-something female. Her lung function tests indicated she was advanced in her disease. In the 'old' days, CF patients would die before reaching adulthood. They are living longer. However, by the time they reach their 40s, they die if they do not get a lung transplant. Studies focus on pulmonary function tests (PFTs) and have correlated FEV1 (measured in percentage of predicted) with life expectancy. A FEV1 of less than 35% indicates a life expectancy of less than 3 years generally. When I admitted her for her bi-annual CF 'tune-up', we got a PFT. Her FEV1 was about 25%. That meant that without a lung transplant she would die in a year. I could see the terror in her eyes. There was no hiding her fate from her. She knew her disease, had watched siblings die and knew the end was near.

Fortunately, she was put on the transplant list and received her lung transplant in time. I had the pleasure of taking out her sutures in the office a few weeks ago and listened to clear lungs.

Another CF adult I inherited was a wayward 20-something. He had had the misfortune of having a childhood cancer, in addition to being the only one of several children in that family with CF. This young man was not very interested in CF bi-annual hospitalizations. He had not come since he was 16. In the years that followed he developed a dreaded lung infection with a bacteria called Burkholderia. This organism is so deadly that CF patients with it are not allowed to attend Cystic Fibrosis meetings for fear that others with CF will contract the infection and may die from it.

I did his PFTs and they had declined from the 70s to the 50s in the space of 4 years. I had to sit him and his parents down and have a hard conversation. I pointed out that at his rate of decline and with Burkolderia, if he continued to live as he did, he would be dead in about 5 years. I had his parents in tears, while the patient looked stoically on.

Fortunately, he stayed the length of time in the hospital and we got his PFTs up to the 80s by intensive antibiotics and much needed pulmonary therapy, with which he cooperated and complied. We pushed death back, I think.

With kids with CF, it was bi-annual CF tune-ups and antibiotics. With the adults, there is watching the PFT decline predictably and waiting for death. I had not expected to be dealing with that. Still, I will care for them -- encouraging, goading, exhorting, doing whatever it takes to extend life.

Time off - part 4

2011-06-18T22:29:00.003-05:00

Here is Piyali, Simon and me at the exit of the cave.

The next day, Piyali took me to see Marshall University. We drove around Huntington and she showed me the stadium (of 'We Are Marshall' fame). Here she is in front of the Marshall University buildings where we going to see Simon and her labs.

It was a true 'vacation' for me to 'forget' medicine for a while and immerse myself in science. Simon patiently walked me through his research. He works on cell communication in Drosophila. Here he is in his lab, 'posing' for my photo -- looking at his beloved Drosophila.

After we finished with his lab, we went over to the medical school and checked out Piyali's lab. She showed me her research work. Here she is at her lab work bench.

We had a wonderful tirpanyaki lunch at a Japanese restaurant down town.

It was a short break, but lots of fun.

Time off - Part 3

2011-06-18T22:20:00.002-05:00

Stalagtites and stalamites join to form pillars, here's one :

Our next stop in the national park was a natural bridge. This is -- as the name suggests -- a bridge over a river or stream that formed naturally. Here it is:

The ceiling of this bridge was spectacular. Here it is:

At the end of that day, we all came home and slept well. It was a fun day.

Time off - Part 2

2011-06-18T21:56:00.008-05:00

Huntington, West Virginia is at the edge of the border of West Virginia, where it joins Kentucky and Ohio. In fact, downtown Huntington is at the edge of the Ohio river and one can stand on the bank of the river and see Ohio on the other side. This is me standing with Ohio in the background.

The second day of my trip, Piyali, Simon and myself drove to Kentucky to the Carter Caves. This was the entrance to cave we went into and our guide. I LOVED the accent of the Kentucky folks!

The cave was beautiful with many natural formations related to the process by which caves are formed. Here is one.

Caves are formed by stalagmites and stalagtites -- limestone dissolving in the water and forming extensions of the ceiling and floor, respectively.

These are stalagmites.

The photo below shows a large stalagtite.

Here is Piyali and Simon inside the cave.

More in Part 3

Time off - Park 1

2011-06-18T21:20:00.004-05:00

During the Memorial Day weekend, I had time off. So, on Saturday morning, I jetted off to visit a friend I had never actually met in person. Piyali Dasgupta have been friends for about 10 years now. We talked on the phone and emailed each other through the years -- she living in various places in the U.S. pursuing her career and me going through medical school, residency and now working here. She recently bought a house and invited me to visit. I was looking forward to meeting her in person. Both she and her boyfriend are professors at Marshall University, so a side treat would be to visit their labs and learn about their research.

Piyali has a beautiful house in Huntington, WV. She told me that the state bird of West Virginia. On her back porch, she has a bowl of birdseed and practically all day, I could see these beautiful birds come to feed. They were very shy so photographing them was difficult. This is the best I could do.

This next picture is taken through the netted window.

More in Part 2

Don't look now, you've turned into your dad...

2011-04-16T09:40:00.002-05:00

I just finished a week on the teaching service in internal medicine. I have now been in practice a little over 2 years. During the week, there were a number of times when I caught myself thinking "wait... I sound like the attending I had as a third year medical student!" It wasn't a bad thought. But it felt like looking in the mirror and seeing your first grey hair or catching yourself thinking 'I sound like my mom or like my dad!'. I guess as one goes through the medical education process -- from the third year medical student doing his or her first clerkship to the time when you are the attending physician, one changes. I felt comfortable in my role. I supervized procedures, stepped in when the resident or student could not get it, and led patient care decisions. I thank God for all my mentors and teachers through the years that have enabled me to step into this position prepared. I pray I will impart and train the next generation of physicians as I was trained.

Rejection

2011-04-16T09:36:00.002-05:00

I suppose that if you practice long enough, you will have this experience. My appointment scheduler came to tell me that one of my patients -- a 2 month old was switching providers. I may have lost patients before, but been blissfully unaware. This time, I knew. Strangely enough, just a week before I had answered a phone call from her mother, weeping on the phone that the baby was not doing well. I lost no time getting in touch with a specialist to weigh in on the problem and called her right back. I thought we had things settled. Apparently not. While I do not resent this mother wanting to take her baby to another doctor elsewhere, it does leave me wonder what I did wrong. I cannot think of anything (that's scary too, no?). Well, I hope the mother and baby do well, and receive the care they merit. I will miss not seeing little one grow up in my practice.

Epilogue: Help us build a hospital in Coatepeque

2011-02-06T15:19:00.006-06:00

Northridge Church has been sending a team yearly for at least the past 9 years. Each year we do something like what I’ve described above. It is a drop in the bucket. King’s Castle (Castillo del Rey) has a beautiful campus. It also has a full-time doctor (Dr. Boris, who comes out with our and other visiting medical teams), and now about 5 nurses, mostly from the U.S. who are full time missionaries there year long.

Here is a photo of Dr. Boris and me (drinking coconut water)

One of the frustrations of our short visits was diagnosing patients with diseases like diabetes, hypertension, hyperthyroidism, chronic medical and surgical problems like cataracts, chronic skin breakdown and infections. It is impossible to treat this with a single doctor’s visit. They need ongoing care. Many of the older population had cataracts, pterigium and other eye problems that are easily corrected surgically. A cataract operation could take as little as 10 minutes in an equipped operation room with appropriate post-operative care. The people that live in the mountainous (altitude of about 600 meters) municipality of Coatepeque (population of 48,544 living in 126.85 km2). To the best of my knowledge, there is no clinic accessible to these people. The closest hospital is in the city of Santa Ana which is about 15 miles away. Since the population is poor, something more accessible is needed. There are concerns regarding parasites (worms and amoebae) in the drinking and bathing water, high levels of arsenic in the water of the lake. There is a great need for treating injuries, infections and acute health problems before they become chronic. There is an inherent mistrust of hospitals. Most people think that if they go to the hospital, they will never come back alive!

We NEED a hospital in this area. Over the past years, Northridge church and other concerned groups have been donating money and bringing down construction teams. The results are what you see below:

The inside looks like this:

Of course, there is no floor and when it gets hot, the horses on campus come and sit inside. $ 16,000 will allow us to put a tiled floor inside, plumbing and doors and windows.
The hospital is about 120 feet long and 60 feet wide. It will have two floors and an access road.

The next step is to raise about $ 20,000. This will give us a floor and plumbing. Once we have these, we can begin to put in windows and doors and set up electricity. With another $ 60,000 we should be able to get the first floor up and running as a functioning hospital. This will include inpatient beds, an operating room and outpatient areas. King’s Castle has housing where visiting medical faculty can stay. We have a number of physicians, surgeons, nurses and therapists willing to come down for periods of time and donate their services. This is, of course, if we have the hospital up and running. I am picking up this vision and shall be working locally (that is, in Marshfield, WI) to raise funds and support for this project. If you would like to help, email me at aswani.vijay@marshfieldclinic.org or aswaniv@hotmail.com ).

The El Salvador 2011 Mission Trip

2011-02-06T15:11:00.000-06:00

From January 28 to February 4, 2011, I was part of a mission trip to El Salvador. This is a trip organized yearly by the Northridge Church in Marshfield, WI (http://northridgefamily.org/). I was excited to go. It was my second trip.

We left on schedule from the church building at about 5 pm on Friday, January 28, 2011, taking a chartered bus to Chicago, IL, from where we were to catch our TACA airlines flight later that night. There were 31 of us, including 5 MDs (a general pediatrician, 2 pediatric neurologists, a plastic surgeon, an ER physician and myself, a combined internal medicine and pediatrics physician) and 2 ER nurses.

When we reached Chicago’s O’Hare airport at about 11 pm, we discovered that there was something wrong with the plane and the only flight that could take all 31 of us was scheduled for Sunday morning, January 30! Oh well, the airline put us at a hotel near the airport until that time and paid for all our meals. It turned out quite nicely actually.

During the next day – Saturday, we got to know each other a little better and had a little R & R.

I think this was the Marriott hotel.
My colleague took a picture of some of our kids holding up their meal vouchers. Don’t they look happy?

On Sunday morning, well rested, we came back to the airport by the hotel’s shuttle bus. Here we are, once again, waiting with our bags in a line to check in to our TACA flight

The El Salvador 2011 Mission Trip - Basics

2011-02-06T15:10:00.000-06:00

So first of all, where is El Salvador and how do you get there from Marshfield, WI? The map below, drawn by Google Earth shows Marshfield, WI, Chicago, IL and San Salvador in El Salvador.

This next map shows Central America and locates El Salvador next to Guatemala and Honduras.

The next map shows the enlarged Google Earth map of El Salvador.

And here is a map of El Salvador showing the major cities and routes.

Of course, other than the little nameless location on the coast of Lago Coatepeque, none of the other places we did missions are on this map, so they are shown below.

El Salvador Mission Trip 2011 - Lago Coatepeque

2011-02-06T15:09:00.000-06:00

This time things went without a hitch. An uneventful flight of about 4 hours later, we arrived in El Salvador. This is what the airport looks like from the outside.

We arrived by about Sunday afternoon. David Heegeman (our team leader and an ER physician) and myself spent a couple of hours delayed in customs. You see, each member of the team carried two bags – one their personal belongings and the other a bag we had packed at the church a week before. This second bag contained medicines, surgical supplies, toys, shoes, and donated clothing. The customs were not happy with 10 bags of medicines, even though they had all been inventoried and detailed, all were within their expiration period and none were controlled substances. Anyway, after going through some paperwork, we were allowed to leave with out medicines.

Our base for the trip was to be Castillo del Rey or King's Castle (http://www.kingscastle.org/MinistryCenters/InternationalTrainingCenter/tabid/619/Default.aspx). It is located on the west coast of Lago Coatepeque. This is a volcanic caldera lake about 28 km2 across with a maximum depth of 1400 feet. It is a coatepeque municipality of the Santa Ana department of El Salvador.

We caught a bus from San Salvador (the capital, and where the airport was) and rode about a couple of hours to the west to campus of Castillo del Rey (King’s Castle) on the edge of the Lago Coatepeque. Here are some pictures of this beautiful lake.

A panoramic view:

More views

Day 1 - El Salvador Mission Trip 2011 - Guadalupe

2011-02-06T15:08:00.000-06:00

Boys and girls were housed in separate dormitories. We (the boys) slept in a dormitory on the top of a hill with a beautiful view of the lake.

The castle like roof at the bottom of this picture is of of dormitory.

That evening, while the evangelism team learned their skits and dances (that they would perform during the days when we would do our medical work), we packed lots of medicines, counting out 30 day supplies of various pills, dispensing out about 60 cc of various syrups into bottles. (You can see a couple of the bags in which we brought the stuff in the back.

Day 1 - El Salvador Mission Trip 2011 - trip to Guadalupe

2011-02-06T15:07:00.000-06:00

Anyway, after a good breakfast, we set out for Guadalupe. We passed some interesting traffic on the way there, like this calf suckling at her mother’s teat in a pickup truck.

The journey to Guadalupe took about 2 and half hours. Guadalupe is a small village.

Where the King’s Castle has a small church community. Once we got there, we began setting up within the church building.

The picture below shows the pharmacy section being set up.

Us doctors set up our section as well and then waiting for our first patient. I’m ready!

Patients would come in and get their vital signs recorded

Once that was done, they would take a seat and pass by to see the doctor in turn.

This picture shows a bunch of girls tickling each other to pass the time while waiting. It was such a cute sight, I had to stop what I was doing and take a picture

Patients would wait their turn and then be seen by the doctors.

I kept track of what I saw and saw about 33 patients that day.

I tapped one swollen knee.

After seeing our patients, they would pass by the ‘pharmacy’ and get their prescriptions.

Both at the beginning and end of each session of seeing patients, we would have to unload and load the bus back up with all our equipment, supplies and medicine. Then there was the long bus ride back to base.

Day 2 – El Salvador Mission Trip 2011 - Dawn and Insect Stories

2011-02-06T15:06:00.001-06:00

Day 2 - January 31, 2011

The next morning, we all got up and after a cold shower, were ready to set off for our first field location, Guadalupe. Outside, we could see the beautiful sunrise...

And horses grazing on the field on the campus.

The girls came down from their dormitories with stories of having found a scorpion on the floor...

They also had a huge (about 5 inches long) grasshopper hanging out on their shower curtain.

These guys were all over the place.

Day 2 - El Salvador Mission Trip 2011 - trip to Candalaria

2011-02-06T15:04:00.000-06:00

February 1, 2011 - Trip to Candalaria

The next day we were ready to get back to work. Today we were scheduled to go even further, to Candelaria to the location of a second church. On the way there, we saw this cool-looking igunana that was about a couple of feet long.

I saw about 42 patients at Candelia, including 2 cases of a rare skin disorder, epidermolysis bullosa. The first patient, shown in the pictures below was only 29 years old but looked more like 60.

The pictures below show the bullae on her hands and the scars from ruptured bullae and sloughed off skin on her back.

Even if she lived in the States, I doubt we could have done a lot for her.

There was also a lot of bad teeth in El Salvador, probably because of no fluoride in the water.

Here's a funny picture of a little boy that does not want the doc to look in his ears.

Seeing a lot of rashes,

white spots on skin

and fungal infections.

Here's our dentist looking happy, tired and ready to work.

It was a busy day of seeing patients.

By the time we got back to base, we were all pretty tired.

Day 3 – El Salvador Mission trip 2011 – trip to Ayutuxtepeque

2011-02-06T15:03:00.000-06:00

Day 3 ; February 2, 2011

On Day 3, we went to the location of the future Dream Center – a project planned by Castillo del Rey. At the moment though, the church has been meeting in a tent for a few years.

On the way to this location, we stopped to the a field of lava rocks. We took some samples as souvenir.

I saw about 41 patients here.

The kids are the most fun to see.

The kids are just the cutest and instead of working, we were tempted to just play.

Day 4 – El Salvador Mission trip 2011 - Lago Coatepeque

2011-02-06T15:00:00.000-06:00

Yay! We don’t have to drive anywhere today because we will seeing patients here at the campus. We set up medical camp in the gym. From about 4:30 am, patients had lined up outside waiting to be seen. Some came on wheelchairs whose wheels were almost falling off. People here walk long distances over hilly terrain (it is after all, a volcanic terrain). We saw a lot of foot problems.

This lady’s feet had dried and formed large cracks like this one.

Others had diabetic sores on their legs.

This young lady had the classic physical exam findings and symptoms of Grave's disease. We had seen her last year too and she was not so far along. Unfortunately, she could not get in to see anyone to care for her. This time, we just bought her the medicine.

Day 4 – El Salvador Mission Trip 2011 - Lago Coatepeque A cauliflower mole

2011-02-06T14:59:00.001-06:00

We saw one 57 year old woman with a large cauliflower mole on her face and removed it for her.

We did this by first cutting the mole out.

Then sewing up the skin.

She didn’t feel a thing because we used local anesthesia. Such simple procedures are forbiddingly expensive and so people live with these skin defects in resignation.

Day 4 – El Salvador Mission Trip 2011 - Lago Coatepeque - treating dehydration

2011-02-06T14:58:00.003-06:00

A 17 year old volunteer came into the gym where we were seeing patients. He had nausea, headaches and did not feel right. After checking him out he seemed quite dehydrated. I was able to place an IV and give him some fluids. This turned him around. Heat exhaustion is an ever present threat to those working in hot climates, especially those who came from chilly Wisconsin.

Day 4 – El Salvador Mission Trip 2011 - Lago Coatepeque Paronychia

2011-02-06T14:58:00.002-06:00

We saw a 70 year old man who had injured his finger a couple of months ago cutting wood. He thought that maybe a splinter got in and had become infected. His finger looked like this.

This is a paronychial abscess.

You could see the bulge in the skin with yellow pus beneath it and increasing redness and swelling.

I numbed up the finger up, cut the abscess open and drained the pus out. He felt much better. After dressing the wound, I sent him home with some antibiotics.

Day 4 – El Salvador Mission Trip 2011 - Lago Coatepeque End of the Day

2011-02-05T23:59:00.001-06:00

I saw about 50 patients that day.

All told, between 6 doctors, we saw about 1000 patients over these 4 days.

After a long but rewarding day, we got to jump in the lake… I mean we got to swim in the crater lake. It is about 1400 feet deep in the center, being a crater lake.

That evening, we were served a traditional El Salvadorian food – pupusa. I loved it.

As a special treat, some of us (those who were willing to have it) got coconut water from the coconut palms that grew on campus.

Here is me with the local doctor there, Dr. Boris.

That evening, our local partners put on a show of El Salvadorian dance for us.

During this program, our hosts said lots of nice things about us. It made me worse to think that here we are who give up 5 days of our comfortable lives in the States while they live in need, and they thank us!

I hope to come back every year and I am going to get involved with the hospital project (see the post nearby).

Day 5 - El Salvador Mission Trip - Going Home

2011-02-05T18:01:00.005-06:00

The next morning was our last day in El Salvador. We had a good breakfast, packed our stuff up and prepared to leave. Before that, we took a few photographs. These show the medical team and then only the doctors and the dentist.

I also took one with William, one of the students on campus who helped us. He is preparing to enter the ministry.

I had a great time during the trip. Unlike last year, this year I boarded the plane to come to El Salvador sick. I had been working in Urgent Care the week prior and had contracted an upper respiratory illness. During the whole trip, I was sneezing and coughing and felt tired. Nevertheless, my discomfort was nothing compared to the need all around me.

I did arrive home with no voice, so my posts will have to serve as my report until I get my voice back.

Camp Angel 2011 Winter Camp

2011-01-23T12:18:00.006-06:00

It's been busy! However, the Camp Angel 2011 Winter camp was on the docket and as always, it was a pleasure to go.

The Camp took place from January 21 to 23, 2011 at Camp Manito-wish YMCA -- a delightful campus (http://www.manito-wish.org/) . There were about 30 boys and girls, ages 8 to 12. A lot of the usual crew of counselors showed up, with some new faces and some that have had to move on (busy with school). Lolly Rose, the founder of Angel on My Shoulder was there, as energetic and charismatic as always. She is a great example of how one can turn a personal tragedy into a blessing for so many (read her story and more about Angel On My Shoulder at http://angelonmyshoulder.org/.

Other volunteers were there too: Dick (whose family has been touched by cancer) and Amy, his fiance, Mike, Donna, Kerri and Jeff and Dr. Bill Hocking. We also had a 4th year medical student, Nathan Zachariah would might come help as a camp doctor.

The campers had a lot of fun, even though the temperature was below zero for part of the camp. It was -13 F (-25 C) this morning. A volunteer brought her beautiful dogs and offered dog sleigh rides to the kids. There was finger painting, face painting and rock painting. Of course, there was also horse sleigh rides, sledding, ice fishing and a talent show.

Other than the bitter cold, we all had a great time. See you all in summer.

'Twas 3 days before Christmas...

2010-12-25T20:37:00.002-06:00

Christmas is a time for joy...but not always. I was on call for pediatrics when my pager went off at 5:30 am in the morning. When I called back the nurse informed me that a kindergartner had passed away. I went in to declare her dead. She had fought cancer and lost. Her mother held her body in her arms and wept. Her father and grandparents stood around the bed. There are no words for times like this. I have had this family in my prayers during this holiday season.

Just a few days ago I had gotten notification that a patient of mine had died in hospice. I remembered the phone call from his aged wife a month ago asking me if I would prescribe home health because she could not no longer move him into a tub or onto a commode by herself. By herself! I remembered encouraging her to bring him in. He would not come. When he finally did, he died 2 days later. Once again, losing a life partner of many decades at a time like this must be crushing. When hollywood shows love, it shows beautiful young people, hands and eyes locked together. However, I see love in this elder woman trying to help her husband onto a commode or into a tub. He has nothing more to give her. She will get nothing in return. She does it just because she loves him. They have shared life, home, bed and children for decades.

My prayers go out to these families and other like them in need, sickness or alone.

Let it snow!

2010-12-12T10:57:00.004-06:00

Aaah! I finally have a weekend off when I am not working the ER, not staffing wards, not in Urgent Care or the newborn nursery. Actually, I was supposed to go to City on a Hill for the monthly free clinic, but the roads were too hazardous to make the three and half hour journey there and back. So I get to spend the weekend at home (could update the blog too :-) ).

Since we have no place to go, let it snow, let it snow, let it snow....er... okay now, enough, please stop!

Been waiting too long?

2010-12-12T10:27:00.005-06:00

It was around Halloween time. The clinic was very busy and a few unexpectedly complex cases had set me behind (can you sense me making excuses yet?). I must have been running about an hour behind schedule.

I walked into the exam room of my next scheduled patient and saw this! I came out as quickly as I could and got my medical assistant to come and look too. We all burst out laughing.

What do you think? Been waiting too long?

Practicing in Resource-Poor settings

2010-12-12T09:50:00.004-06:00

At City on a Hill's monthly free clinic, one gets to practice medicine a little differently than at my usual place of work. For one thing, we do not have access to the same resources (labs, imaging, sub-specialties) that one has in a larger clinic, multi-specialty venue or hospital. And yet, patients may have problems that could benefit from this. I saw a woman with an obvious goiter. Interestingly, her mother had the same thing. They had lived their entire lives in the U.S. in a city. She had mixed symptoms of both hyper and hypothyroidism. Management is proving to be challenging. I chatted with an endocrinologist friend who is from India. He suggested some physical exam techniques and history I could obtain to help manage her without further expensive imaging. I benefited from his experience managing patients in a resource-poor setting.

BRCA1

2010-12-09T11:11:00.002-06:00

I love taking care of entire familes. It gives me the opportunity to know the pertinent medical history of not just the patient, but his or her relatives too. It introduces me to the support system (or failure thereof), the psychosocial environment and allows me to effect changes that benefit everyone in the home (like in diet, smoking habits and such). Sometimes though, while the opportunities to care for the whole family are beneficial, they are not joyful.

I have one such somewhat disjointed family in my practice. I take care of 3 generations of women -- a grandmother, her young daughter and that daughter's toddler. recently, grandmother -- a somewhat young lady in her mid-40s found a lump in her breast. We got the biopsy and it was positive for cancer. Because of her age, we checked her for the dreaded BRCA1 mutation. She was positive. This means that her daughter and grand-daughter are at increased risk too. Deleterious mutations in the BRCA1 gene may confer as much as an 87% risk of breast cancer and a 44% risk of ovarian cancer by age 70 in women (Lancet 343: 692-695, 1994). This also confers a 20% risk of a second breast cancer within 5 years of the first and a 10-fold increase in the risk of subsequent ovarian cancer. Her daughter and grand-daughter have a one-in-two chance of having this mutation

This is crushing news for these 3 generations of women. Recommendations go even as far as prophylactic bilateral mastectomies (removal of both breast completely to prevent developing breast cancer. The younger women will need yearly mammogram and/or breast MRIs from age 25 upwards.

Temporary Insanity

2010-09-26T19:07:00.002-05:00

Life as a physician is busy. It would be wonderful to have a day to just read: textbooks, journal articles, look up stuff relating to perplexing cases, but that does not happen. It would be nice to come home not completely spent emotionally, physically and mentally and have a second wind to do something else. Not usually on a weekday.

The solution: temporary insanity.

Every so often, I get a complete weekend off -- no call, no volunteer work scheduled, no extra shifts, (we'll not talk about the piled up reading, studying for boards, doing CME activity, it'll be our little secret). This is not often, you understand.

That's when it happens: temporary insanity.

For 2 glorious days, I am not a doctor, not a scientist and sometimes, not even a sentient being. I eat. I sleep. I watch a nonsensical movie. I buy a comicbook or a science fiction mag. I vegetate. It's like a mini-vacation. It's pretending that there are no pending deadlines, it's supressing the perpetual guilt one feels for not studying enough, not reading enough, not being up to date with every last shred of paperwork, not having answered every last email, not having cleaned the bathtub in a while, or the kitchen, or ...never mind. Temporary insanity makes it all go away. It feels good. In the words of a country song I heard "I don't have to be me till Monday."

20 minutes

2010-09-26T18:53:00.003-05:00

What does 20 minutes to you? To me, during the work day, it is the length of time I have to spend with my patient who is here for anything but a complete physical. It doesn't matter: cough, cold, diarrhea, feeling suicidal, family crisis, swollen knee that needs fluid taken off, or discussing the test results that reveals a possible malignancy. I often joke about having to solve the world's problems in 20 minutes -- that is primary care. Of course, I exaggerate a little and jest a little, but only a little.

Er... did I mention, I usually run late and work through most lunches? You might wonder what the problem is: why can't we take more time with our patients? The answer is logistic, philosophic and economic and part mystery (to me, anyway). I understand but I don't understand. Ever been there?

One problem is advanced access: the number of days it takes to be able to see your doctor if you call, the first available appointment to establish care, or for follow up or for an acute problem. You could go to the ER or urgent care, but then, why have a doctor if you can never get in to see him or her when you need him/her? The other aspect is economic: primary care is reimbursed not for the amount of time you spent, but for the type of visit (office visit, often called an E & M [evaluation and management] visit) and the number of diagnosis made. These are paid at a much lower rate that a procedure of equivalent time by most payors (the government, insurance companies and such). Consequently, the only way to 'break even' (balance the cost of running a clinic that does primary care) is to see more patients in a given day.

Again, I don't understand it all. It sometimes seems like a factory (with terms like productivity, number of patients seen per unit time or in our world RVUs generated (RVU=revenue value units).

I try to spend as much time as the situation seems to require. I do not look at the clock or 'kick' a needy patient out because their 'time's up'. Consequently, as the day advances, I fall behind and my patients may get a bit flustered because they showed up on time for an appointment and find that they have to wait an extra 20 to 45 minutes.

By the way, there is no allocated time for phone calls, emails, pages, filling out forms or signing prescriptions to be called in. Those are squeezed in as you walk out of one room and before you walk into the next. You also need to document the visit (we dictate our clinical notes) and bill (to register the diagnosis).

Pause.

It's madness. It's a sisiphial task. It's frustrating. But, I LOVE what I do, I LOVE seeing patients and (hopefully on most days) making a difference and yes, sometimes, on a good day, I do solve the world's problems in the magical 20 minutes. :-)

A mother's worst nightmare

2010-09-26T18:46:00.003-05:00

The story has been heard before, but this is the first time I was part of it. I have a young adult girl and her family in my practice. On a Monday morning I got a phone call from her mother that she was raped over the weekend.

Stop here for a moment.

In the middle of a busy Monday morning rush of patients waiting in rooms to be seen, phone calls to be answers, the pager going off and my email inbox warning me that there were several unread messages, time stood still.

Her friend invited her to a party on a Saturday night and introduced her to a boy. One thing led to the next and there she was in the ER. She said 'no' but maybe too late? Although a young adult, she lives with her parents and has some issues with depression and some developmental delay. A rape kit was collected, although it was locked away because she did not want to press charges because "I don't want him to get into trouble". The next day however, she changed her mind and the wheels are set into motion.

We treated her for potential sexually transmitted disease exposure, tested her for pregnancy and set up an appointment for her counselor.

Running behind. My medical assistant reminds me that room 2 is a 1-month old baby boy here for a well child visit with his parents. I put my feelings in the ice box, put a smile on my face and walk in to a happy family.

City on a Hill -- A free medical clinic

2010-09-26T18:19:00.007-05:00

Every second Saturday of the month I try to go over to Milwaukee to work at the Free Medical Clinic. This is run by a missionary organization called City on a Hill (http://www.cityonahillmilwaukee.org/) that does wonderful work in inner city Milwaukee. The clinic is held every second Saturday of the month. It runs from noon till about 5 pm. Anyone can come. No money is charged. The photo alongside shows the last of several hundred poeple getting in on a Saturday afternoon in September 2010. Did I mention, there is a free lunch and an opportunity to take home a grocery bags of basic foods?

Most medications are provided with the visit, free of charge. This is an amazing work. There are about 3-5 doctors who volunteer on a regular basis. We have a filing cabinet and each patient has a 'chart'. Vitals are taken by volunteer nurses. There are allied services such as free foot care, smoking cessation, flu shots (in the season) and occassionally optometry and physical therapy.

Diagnosis is an interesting experience. Labs and x-rays are very expensive and not available on site. Most diagnosis therefore relies heavily on history and physical exam (aren't we supposed to be able to diagnose most things that way? ;-) ). I have gotten to hear some interesting aortic stenosis murmurs, perform incision and drainage of a cyst, clean out a cerumen impacted ear using a syringe and an IV catheter and palpate some impressive goiters like this one.

In medical school, I was taught the biopsychosocial model of medicine. I believe in the biopsychosociospiritual model: illnesses can have a spiritual component as well. Poor choices or decisions in life, unforgiveness, bitterness, anxiety, guilt -- where else can you place these in the biopsychosocial model?

Working here once a month teaches me to appreciate what we have. The first time I went, I treated a homeless man for pneumonia and a family for scabies. I could not believe I was in one of major cities in the United States.

We sometimes have premeds and medical students come along and with the patient's permission shadow us while we work. We often have to write out our own labels for the prescriptions, count out the pills and fill the bottles ourselves and then explain the instructions to the patient. It gives one a sense of appreciation for other members of the medical team that we have back in our 'not-free' clinics -- receptionists, medical assistants, nurses and pharmacists to mention a few.

Perhaps the most touching aspect of the work is how grateful the patients are that we come. They say thank you again and again, as if we are the ones that are inconvenienced and suffering. I don't presume to know how to fix our broken healthcare system, but when I see out of work, homeless folk with diabetes, hypertension, skin conditions and other chronic medical problems who must make do with a once a month free clinic with a limited selection of drugs, I know I must do something. So I go.

SCFE, suicides, crisis and happy endings...

2010-08-27T22:21:00.004-05:00

My last afternoon at work before I left for a couple of days (to do a Board exam) was kind of heavy. A young lady (pre-teen) came in for evaluation of hip pain and a limp. As she told me the story and I noted that she was obese, I was almost sure of the diagnosis before I asked her to get onto the examination table. As she was doing that, her mother told me that she had SCFE at about that age. I stopped in my tracks. That was the diagnosis I had in mind and was afraid I would find. SCFE stands for Slipped Capital Femoral Epiphysis. It is where the head of the femur (thigh bone) slips off its neck slightly. If not corrected, it can lead to hip dislocation, loss of the femural head (due to necrosis) and some pretty severe disability. Unfortunately, the only way to correct it is surgery. Pins are placed in the head of the femur connecting it to the neck (of the femur). On x-ray, SCFE looks like a scoop of ice-cream slipping off the cone (kind of appropriate image for summer time). I got the x-ray. The diagnosis was confirmed. Most 12-something year olds do not know what SCFE is. Unfortunately, this one did and immediately began to cry "I don't want pins!" Evidently, she had seen mom's scars and heard the stories. My heart went out to her.

Later that afternoon, I got to see an older girl -- a 3o-something. The appointment schedule said 'depression' and in dispassionate computer print on my screen told me I had 20 minutes. Needless to say, a box of tissues was involved, a pelvic exam and screening for sexually transmitted diseases and definitely more than 20 minutes were needed and spent.

At the end of the day, I get to take them all home. Not literally, of course. Nevertheless, they come home with me. It's Friday night -- a couple of days later, and 10:30 pm. I'm sitting in the dark in front of a computer screen writing this blog entry because I'm still thinking about them.

This afternoon while driving to the DMV to get my license updated, I saw a patient of mine walking in town. Just last week, this macho 50-something biker had sat in my office and bawled like a baby. About a year ago, he came in with back and leg pain. In the course of working this up, we diagnosed him with prostate cancer. He underwent a spiffy robotic surgical procedure to remove the cancer (and most of the prostate). Everything went well in that he has no cancer. The collateral damage is not so good. He lost the ability to have an erection. For a month, he was loaned a pump device that enabled him to get an erection. The pump had to be returned since it was a trial and he could not afford it. The reason he was crying in my office was that his fiance of 4 years was leaving him. There was some infidelity involved (it was not him) and she did not want to continue with someone who could not...well you know. He wanted to kill himself. He wished he had never had the surgery. Oh, and he still has leg pain. Ah, the wonders of modern medicine, no?

Okay. It's not all depressing. I don't know why, but the sad cases stay with me longer than the happy ones. Maybe it's my personality type. Maybe most people come to the doctor when something is wrong, not when things are going well.

It's summer time and was the last week of summer vacation (alas, for the school kids, not me). I've had a lot of kids in here for their sports physicals and 'back to school' exams. I enjoyed seeing lots of happy kids with stories of adventures and vacations during summer. Some have scars, scrapes, and tans to prove it too.

Several of my co-workers from my residency days have had babies and picked me to be their baby's doctor. I feel like a chosen godfather, an unofficial grandfather, a surrogate dad and big brother all in one. I've kept my professional demeanor (well, sort of) but I'd rather leap out of the white coat, hug them and then dance across the hall with their newborn craddled in my arms. Okay, so I can't do that on the outside. But hey, I'm dancing on the inside and no one can stop that. Of course, nervous nellie that I am, I examine these babies carefully. I listen to every historical detail the parents offer. I don't what to miss anything bad but I don't want to find anything bad either. Truth be told though, if there's something to be found or diagnosed or treated, I'd rather it be me doing that that someone else. That's why I do this. Those are my babies too!

Okay, good night!

Nightmare

2010-08-07T09:43:00.003-05:00

I don't know why, but for the last few nights I have been dreaming I'm at work -- either at the hospital or the clinic. Last night I had a nightmare. I was in a small ER somewhere and my patient was a 1 month old baby that was not doing well. I was doing a spinal tap and the CSF (cerebrospinal fluid) was turbid like dishwater. This child had bacterial meningitis and was dying! I began barking out orders and trying to get this child to the intensive care unit in Marshfield. It was chaos and a race against time.

The situation changed and I was on Isla Bastimentos in Panama, back among the Ngobe. This time I was tapping an older infant with improvised equipment in a barebones clinic and getting the same dishwater CSF. I began to cry because children were dying on meningitis and I could not save them. I managed to save 6 kids by giving them antibiotics in time, but one kid died. We did not have enough ceftriaxone, we did not have enough spinal tap kits or needles or syringes or IV start kits. I woke up crying. It is really hard to know what to do and watch helplessly as a patient dies because you do not have the tools you need. Wow, it took me quite a while to shake that off. It was so vivid. Brrrrrr!

The weeks

2010-08-06T15:19:00.003-05:00

My practice is growing. I know have about 1100 patients that call me their doctor. Most days, clinic is a whirlwind of patient visits, emails, phone calls, and reviewing labs, imaging studies and reviewing nurses' notes and consults.

Last week, one of my patients called to say that she had felt a lump in her breast that was not there when I saw her for a physical in November. Her insurance was not going to cover an office visit, so she requested if I could just order the mammogram. I did. A mass was discovered in her right breast and a sample biopsied. The result: invasive lobular carcinoma. I called her to give her the results. She would not answer the phone or speak. Instead, her husband was to receive the bad news. I hate this part of my job -- giving bad news. Actually, I don't hate that part. I want to be there for my patients. It's the bad news part I hate. Every diagnosis weighs heavily on both my patient and me -- some like cancer more so than others. Sometimes though, a diagnosis is a relief. I got to call a patient who for years had been suffering with pain in the upper and lower abdomen. He was so frustrated that no-one knew what it was. This week, we finally found out: epiploic appendigitis. It may be chronic or it may respond to treatment, but for the moment, we both savored the pleasure of the end of one journey -- the 'what's wrong with me?' part, before embarking on the 'how do we fix it?' part.

I also got to diagnose hemachromatosis for the first time. This is a disease I had read about in textbooks but never actually seen. Making the diagnosis was like an 'aha' moment that suddenly pulled all of the symptoms the patient had, come together into a coherent picture.

The weeks are bitter-sweet: the treating of patients that get better, the diagnosing of patients who may or may not get better, depending on the diagnosis, the tearful goodbyes to patients who die, expectedly or unexpectedly and the cheerful hellos to the newborn babies born to my patients or as new additions to their families. They all run together in the same day, sometimes in the same afternoon. It is like a roller-coaster ride, emotionally, physically and mentally.

Most nights I arrive home spent. These days I dream of the clinic and the hospital. Some mornings I wake up feeling like it's not fair -- I feel like I just worked all night. Still, I am tired but happy.

I still got to say: this is so cool! Thank you Lord, for the privilege of seeing patients and practicing medicine!

Death and Birth

2010-08-06T15:05:00.003-05:00

The pager vibrated where it sat on my table next to my desk lamp. I was sipping coffee at 5:00 am when I picked it up to see who was paging me. I was on call that weekend and it was a Sunday morning. The message was the one we never like to see: pediatric code blue, ER 15 minutes. I dressed hastily and got to the ER as fast as I could. Although I was on call, I was not on call as as a first responder. That job fell to the pediatric intensivist and residents on call. I went anyway. By the time I got to the ER, they were already there and CPR was well into 10 minutes. The 4-month old baby was pale and lifeless, pupils fixed and dilated with no pulse and no respirations. The code ran about an hour before it was stopped. The coroner would be doing an autopsy because of the untimely death of this previously healthy baby. Apparently, the night before, the infant had been fussy so his parents brought him into their bed. Cause of death was most likely SIDS (Sudden Infant Death Syndrome).

As I walked out of the ER, I could not help but remember the last time something happened, that I was a part of. It was during my intern year and the code came at the end of a 30-hour call period. I remember coming back to my car numb and crying as I sat in the drivers seat, overwhelmed, tired, shocked and heartbroken.

This time, I got back in my car, drove home, showered and returned to the hospital to see newborns. I'm not an intern anymore. I can't say I feel nothing, but I was not as overwhelmed as I was the first time. That morning, my responsibilities included performing the newborn exam on all the babies that had been born overnight. As I looked into their little faces, I could not help but smile while in my mind was the image of the dead baby I had seen only an hour or two ago. From death to birth in a morning. That is medicine.

Camp Angel Summer 2010

2010-07-18T11:48:00.005-05:00

Wow, looking over this blog, I can see that I have not been writing much. This is not because nothing's happening. Rather, it is the opposite. I will try to do better. Well, July 9 through 11, I was at the summer Camp Angel. To learn more about Camp Angel, visit their website: http://www.angelonmyshoulder.org/cancer-support-programs/31-camp-angel/132-camp-angel-activities.html.

Like last year, this camp was held near Three Rivers in northern Wisconsin at Camp Luther (http://www.campluther.com/) . Camp Luther is a beautiful facility with several different kinds of camp buildings for the kids: a fort, a tower, an Ark and other wooden, fun architectures that make an adventure out of staying there.

This year there were 24 children, an equal number of boys and girls. As with each year, they were divided into groups according to ages. The 8 and 9 year old girls were called the Bunnies, the 8 and 9 year old boys, the Bears, the 10 through 12 year old girls the Foxes and the 10 through 12 year old boys the Wolves. Each group had 2 to 3 counselors. Every year the groups do fun things with their names like 'the Foxy Ladies' and the boys shouting, "Who Rocks? THE BEARS!"

When the kids get off the bus, one tends to see... kids. But if one sits down and reads their application forms, one sees the heartbreaking stories behind them. One of the children lost his dad to cancer only in April. Others have lost a mom or grandparent. Others have a sibling with cancer. What does this do to a kid? We had one little girl on 2 sleeping pills, something to prevent her wetting her bed and something for acidity. Those of us administering the medications shook our heads in increduility and dismay even as this 8 year old pointed to each tablet and told us why she had to take it. A number of kids were on antacids, ADHD medication or something for chronic headaches. Processing the stress of a close family member with cancer can code in their little bodies as psychosomatic illnesses, behavioral problems or actual physical ailments.

One little girl got off the bus and was brought straight to me: "She threw up the whole way here!" She had a headache and did not feel good. I took her to the medical room and encouraged fluids.

That evening, we had a scavenger hunt with the kids having to find things like a bronze bowling pin, a particular kind of feather, eggs and other items skillfully hidden on the grounds by their counselors. As happens every year, the Northern Wisconsin Harley Davidson group drove in revving up their motors to make a grand entrance. The kids gazed wide-eyed at the shiny motorbikes. Several took pictures sitting on one or more of the bikes. I held onto one 11 year old who had just been dropped off by his parents. He didn't feel like being there and was teary eyed as his family drove away with the admonition: have fun!

The next day was our main day on camp. After a good breakfast, buses of us set out for Three Rivers and Duck Lake, where Captain Steven and his son Steve-O had a pirate ship ready and waiting for us (http://www.eagleriverpirates.com/). Before that however, I made a quick trip into town to pick up some anti-nausea medication for a few kids who, it turned out, had motion sickness. I also stocked up on hydrocortisone for bug bites, Aloe with some lidocaine for bad sunburns and some children's peptobismol. During the pirate ship adventure, most of the kids had fun. Captain Steve showed us a bald eagle's nest with a couple of birds in it. With pirate songs playing in the background ("My name is Roger, and my favorite letter is 'ARRRRHH"), we blew bubbles, and colored white T-shirts with pirate-themed pictures. Counselors and myself looked out for kids that seemed to take themselves out of the fun because of depression or sickness and helped.

In the afternoon after lunch which was a yummy cookout, we all got into the water. Kids jumped off the pier, swung on a rope for a splashy landing in the water, rode on tubes pulled by jet skis and motorboats and went fishing. We had a few sunburns, scrapes and and nausea but nothing major. I stayed in the water and helped kids on and off the tubes. I smiled at one group of 3 8-year olds who had never been tubing and wanted to try it for the first time. As the motorboat pulled them across the lake, I could see the waves and wind cause the tube to skip and bob on the water, causing their little bodies to bounce, and they held on with two hands to little handles on the tubes. When the tube came to shore, their faces were white and eyes wide. They broke into smiles and pleaded "can we go again?" One little girl went 5 times.

Kids took breaks to get their hair braided, face painted, play shuffleboard or paint souvenir rocks to take home.

After cleaning up, we gathered outdoors for DJ Dan and his music. We got almost everyone out on the floor to dance. It was a fun evening. After that, the campers went back to their camps for s'mores, a bonfire and whatever late night activities naughty campers do.

The next morning, after a breakfast, everyone got back on the bus to go home. There were lots of hugs, smiles and some sweet sadness of saying goodbyes.

Camp Angel is magic for these children. For a few days, they get to forget the solemnity of death, hospitals and sickness. They get to be kids. As a camp medical careprovider, I have learned to balance giving attention to illness, treating what needs treatment and otherwise distracting kids from their illness with some magical results. The camps have taught me that sometimes, distraction is much better than a pain reliever or stomach medicine and sometimes validation of a need is more important than treating it with something.

Kids are magic and seeing them have fun is rejuvenating for those of us adults who were there. I got my Camp Angel rock as a souvenir. Mine has a rocket ship on it. Well, I did have a blast!

MUA - where I went to medical school

2010-07-04T22:26:00.003-05:00

I get a fair amount of queries on Facebook and such about MUA -- the Medical University of the Americas and what my experience there was. Many inquirers want to know if the school is 'real' and whether they can succeed and get into residency in the United States or Canada after graduating from there. After writing individual replies (typed these days, painfully, on an iTouch) I decided it might be best to post this and send inquirers a link. I still try to reply with a personal message to each one, but so many people ask so many of the same questions, this just makes sense.

If memory serves me right, I joined MUA in January 2001. The school was (I think) in its second semester on the island. I had flown down to the island to visit several month before when the classrooms were still being constructed, the pool was a hole in the ground, the library building did not exist yet and there were no students. It was scary and I was not sure if I was doing the right thing.

I graduated from MUA in 2005 and began residency that same year. For the two and half years I was on Nevis, I bought took all my classes and taught biochemistry (this is why it took me a little longer to complete the Basic Sciences curriculum).

Okay, so here's the big picture... the things that really matter. MUA graduates have got into many different residency programs -- community to university-based programs in competitive specialties like neurosurgery, radiology emergency medicine, general surgery and practically every available type of residency program. Many were chief residents of their program in their final years. Many have gone on to do subspecialty training in fields like cardiology, endocrinology, nephrology, critical care, oncology and subspecialties in anesthesia like interventional pain management. This is only based on the people I know personally.

Bottom-line: the school delivers. We are proof of that.

Second-years have to do the United States Medical Licensing Exam Step1. There are 2 additional steps. I personlly know MUA students who have gotten in the 97 to 99 percentiles in these exams. These are very good scores.

Caribbean medical schools come in many shapes and sizes and degrees of credibility. I cannot authoritatively comment on any of them except the school I went to. In MUA's case, I can vouch for the school as a product of it who is a licensed physician in internal medicine and pediatrics and a clinical professor of these specialties with the University of Wisconsin.

Because the standards for getting into the schools in the Caribbean are not the same as those in the States, a number of students will get in that will never graduate. Some will never finish the Basic Sciences. Others will complete their time on the island but not pass the USMLE exam(s). Still others will graduate and never get into residency. I think this is because not everyone who gets into medical school is there for the right reasons. Some are there to please their parents and are trying to fulfill their ambitions. Others think that it would be really 'cool' to be a doctor, but have not sat down and counted the cost. Others have underestimated the sacrifice, hard work and years of training it takes to succeed.

Life as a caribbean medical school student is hard. Some people have a prejudice against caribean medical school students and graduates, thinking they are second-rate because they did not get into a U.S. (or Canadian) school. The interesting thing is that once you're in the hospital (third and fourth years), most people evaluate you by your performance and not your label. The Basic Sciences Dean at the time of my graduation from the island gave us this advice:

1. Be the first to arrive and the last to leave
2. Volunteer for everything ('who wants to look this up? Who want to try to start this IV?)
3. Own your patient (know their labs, their care plan, read on their diagnosis, evaluation and management).

I took this advice and did great. It was an honor to be a Chief Resident, to win an award for the Best resident teacher -- an award given by U.S. medical school graduates who were in training in my institute, and to be asked to join the faculty of our residency upon graduation from our program. I owe my school for these opportunities. MUA took me a student and gave me the instruction in the basic sciences, placed me in my third and fourth year clinicals, wrote my Dean's letter, gave me my degree and enabled me to get into residency and get licensed to practice medicine. What more can a school do?

The rest is up to you.

Camp Angel, Winter 2010

2010-05-01T10:48:00.005-05:00

This is WAY overdue...

I spent a weekend as the doc for Camp Angel (Jan 22 to 24, 2010). To those of you who don't know... this is a camp held for children whose families have been touched by cancer.

It is one of several camps held by Angel On My Shoulder Non Profit Cancer Foundation. (Visit their web site at http://www.angelonmyshoulder.org/cancer-support-programs/31-camp-angel/132-camp-angel-activities.html to see reports on the camps and explore).

This year we had professional photographers, Lisa and Dennis Dewane (http://newdaephotography.com/) who took awesome photos.

Every year we get a sweatshirt or T-shirt, This year's winter came sweat shirt was in camoflauge to honor an old camp counselor, Sgt. Ryan Adams who died serving his country in October 2009.

We had a lot of fun and there were no medical problems. Loved it.

I encourage you to visit the Angel on My Shoulder web site and support this noble work if you can.

What a week!

2010-04-30T20:19:00.002-05:00

Wow! It's the last day of April and I haven't written for so long...

One 'surprise' of being out of residency is that the 80-hour work-week ends. I was on call for Peds Thursday through Sunday. So I am so looking forward to this weekend off.

Last weekend I was on call and it was Prom weekend. Some teenage girl angst that I do not want to get into right now.

This may have been one of my worst weeks since starting in practice.

This week alone, I diagnosed 2 cases of breast cancer, one case of an atypical pre-cancerous breast mass, 2 new cases of diabetes and one unexpected prostate cancer.

I have done a lot of breast exams before this week, but I am changed in how I do them now. There is a pit at the bottom of my stomach when I am doing them now.

This 60-something gentleman came into my office for a physical (his wife made him come). He was on no medications and warned me that he did not want any tests. I talked him into a prostate screening test, and a diabetes screening test. He has prostate cancer and severe uncontrolled diabetes. I almost feel like I gave it to him and in a sense, I did. He was living his life without any labels and now he has two he did not want in the first place.

I've said this before. Medicine is a funny thing. In a day's schedule filled with 15 patients with 20 minutes per patient sometimes, you have to be able to go from one room where you said "I have bad news: you have prostate cancer" to a 2-month old well child exam where you get to say "He's doing great!" For me, it's when the day is over and I am spent, that it hits me.

I joke with my patients a lot. We try to keep the encounter light. I can't forget though, that this is serious business and under the veneer of the routine physical exam, cancer and death may lurk.

Trust

2009-12-28T20:01:00.002-06:00

I have just read some devastating news. A gastroenterologist known to me professionally has been arrested for fondling his patients while they were under sedation. This is shocking in so many ways. First, there is the betrayal of a sacred trust between a doctor and his or her patient. Second, this man was a very accomplished, scholarly and outstanding citizen, who had even served his country in the Armed Forces. Thirdly, he was a christian, a father who had adopted children from a third world country and one known for compassion and excellence. I have worked in that department and I am not sure how he could be alone with the patient to have indulged in this behavior. There is normally always a nurse, a tech or a family member present. There are always people walking around -- nurses, tech, transport people.

I pray for his family, for his patients -- both the ones who were victims and the ones who are bereft of a good doctor, and lastly for him too. I pray that he finds redemption, repentence and that he seeks for and receives foregiveness and mercy at His Throne of grace.

This is scary stuff. Let each of us examine ourselves and take warning and caution.

The missing urine sample

2009-12-28T19:54:00.002-06:00

I worked over Christmas. The day after Christmas a concerned mom brought in a little girl with a fever. I suspected a urinary tract infection as the cause and suggested we get a sample of urine. Since she was not potty-trained, the recommended method for obtaining a noncontaminated sample was to catheterize her. Of course, this is painful and unpleasant, but mom consented, given that it was the best way to be sure this was what was wrong. Two hours after the sample was obtained, I was surprised that a urinalysis result was not back yet. I called the lab and was informed they never received the sample! After several frantic phone calls, the sample was located. It turns out it was not lost. It had been processed both for culture and analysis.

This got me thinking. Snafus happen in every work setting: files get misplaced, entries posted to the wrong account, names mis-spelled, what have you. However, when a sample is obtained at the cost of pain to a little child, it smarts so much if that sample is unretrievable. Clinical information is obtained at the cost of pain and risk to a patient: a lumbar puncture to obtain cerebrospinal fluid, catheterization to obtain a urinary sample, blood draws. I guess everyone thinks their particular work environment is special and I am not exempt from that bias. I'm just glad we found the specimen and could process it correctly. She did have a urinary tract infection and she is being treated. All's well that ends well.

Exhausted!

2009-12-19T17:07:00.002-06:00

What a week! I am exhausted in every way. Let me give you the short version as I am too tired to write more for now:
A man with no anus (status post colectomy) -- remember the old advice you got in med school about the only time you cannot do a rectal exam?
A drug-seeking male/female who had undergone a sex change (male to female) with breast implants, -- claims he/she can have sex and orgasms
A domestic violence case with neglected children and a battered wife
An infected artificial knee with large effusion and gout
Too many other things to remember.

I shall be vegetating this weekend...for a while, then I got to go in and catch up with paper work, dictations, billing and letters to patients on labs done, phone calls, emails...ah, the life of a primary care doc!

Isla Bastimentos and the Ngobe

2009-12-19T17:02:00.004-06:00

Here is some logistics, facts and trivia gathered on the trip:

There are two schools on isla Bastimentos, one with about 90 kids and othe other with 30 kids. There is no school transport and kids walk to school along the coast. Most do not know how to swim and there has been at least one drowning of a 9 year old recently.
There are Nogbe communities on: Isla Bastimentos (about 2-3 communities), Charcot, La Loma, Salt Creek, Isla Cristobal and Isla Carinero, and on Isla Solarte. There are about 6 huts near the 'Bat Cave'
Healthcare facilities (such as they are) include the hospital in Bocas del Toro, another in Changuinola and a quite decent hospital in David. There is a first aid station on isla Cristobal, Almirante and Charcot.
Transport between these facilities is by boat -- expensive, hazardous and slow.

Medical missions trip to Bocas del Toro

2009-12-19T16:06:00.006-06:00

Wild cacao growing on Isla Bastimentos. View of the town of Bocas del Toro from the air.

View from the balcony of the the Kapsars' home The hut where the lady with arthritis lives

on Isla Bastimentos.

Another view of the same hut A Ngobe village
I am writing this so-ooo late! During my visit to Panama, I had a memorable visit with Dale and Kim Kapsar (http://agapeinpanama.blogspot.com/). They live on the island of Isla Bastimentos, one of the islands in the Bocas del Toro archipelago in Western Panama. On this and adjoining islands live a group of Indians called the Ngobe (the 'g' is silent in pronunciation and the 'e' is sounded as 'ay').

Dale and Kim Kapsar have lived on this island for several years now. Their house itself is quite a marvel, with solar roofing to generate electricity, a rainwater collection system that connects to 2 large tanks to provide running water through the plumbing and a tower to connect wirelessly to existing internet providers in the larger area. Dale and Kim have made Isla Bastimentos their home and the Ngobe their mission field, trying to reach them with the good news about Jesus. They however, are keenly interested in their socioeconomic situation too, developing projects to bring potable water to their communities, local sanitation facilities, teaching hygiene to local school children and providing basic medical care. They encourage support not to give gifts to the local indians, but jobs instead through which they can provide for their families.
View of some of the less inhabited islands from the air.
Throug the past year I corresponded with them through email. When I visited Panama to spend a 2 and half week vacation visiting my family there, I resolved to visit them. My family graciously agreed to let me go for 3 days.

I caught a flight from Panama city to the only commercial airport in the province of Bocas del Toro. Here is a picture of the local airport from the inside. I caught the 45 minute flight and arrived in the town of Bocas del Toro. Dale and Kim received me and we had breakfast in the town. After picking up some supplies, we took their boat, Agape, (shown here with Dale standing next to it) to Isla Bastimentos. The trip lasted about 20 minutes and included a stop at the 'gas station' shown here.

Travelling among the islands in Bocas is interesting. There is no public pier or dock at the town of Bocas del Toro on the island of COlon where the airport is located. Boat owner who live on the other islands make deals with local residents to tether their boats at the small piers in their 'back yards'. It costs about $ 30 in fuel and takes anywhere from 20 to 40 minutes to go between islands, depending on how far apart the islands are. Since there are no buoys or lights and their are unmarked shallow reefs, travelling in the dark is hazardous. Travelling in torrential rain (not uncommon in the area) is similarly difficult.

The island shown in this picture is Isla Solarte and the tip shown here is called Hospital Point (http://www.worldheadquarters.com/panama/destinations/bocas/hospital_point/index.html). As someone who is interested in the healthcare resources in the area, this perked my interest, hence the photo. Well, it turns out that it WAS the location of the medical center for a banana company that was located in the area and no longer has anything to do with hospitals or healthcare.

There are numerous mangrove islands that are quite beautiful to look at and here is a picture of one on the way.

The picture below shows Isla Bastimentos and the Kapsar's home located on higher ground.

When we arrived on the island, our first stop was in a small, half-finished building that will (we hope) eventually become a local clinic. Living there presently was a family, one of the members of whom works for the Kapsars. One the phone the day before my flight to Bocas, the Kapsars had told me of a little boy called Aljillo. This was a 2 year old who weighed about 15 pounds and did not walk. He was very malnourished. Here is his picture.

As we walked off the Kapsars' boat, visiting him was my first stop. He had evidence of malnutrition, scabies, lymphadenopathy everywhere I looked. I treated him with something for worms, another pill for parasites, an intramuscular dose of a broad-spectrum antibiotic and gave the family a multi-vitamin and iron syrup to give him daily. I also recommended passive range of motion of his extremities. Within a few days, his lymphadenopathy had subsided and he was ravenous.

After I left, a YWAM (Youth with a Mission) team continued to care and before they left, this little boy was walking! It turned out that the family was not feeding him because he was born out of wedlock. We tried to arrange to get him into a Nutri-Hogar (a home run by the catholic church on the mainland that provides nutrition to malnourished children before returning them to their families.). However, the family left before we could do this.

Later that day, we visited a local school and participated in a group discussion on how things were going with the newly constructed latrine. The following day we visited a local village and saw several children. I treated impetigo (click on the picture of the little boy and look closely at his face, near his nose), scabies and one elderly woman with severe arthritis. The day before I left, Dale cut his hand and I was able to teach Kim how to suture lacerations -- a very common problem they must deal with.

Teams that have come before me have left medical supplies and I left my stock of brough antibiotics, and supplies too. Here are pictures of my flight back home.

Coming back to Panama I began to research what is known about the Ngobe and their health problems. Infant mortality is highest among the Ngobe compared to the rest of Panama and it is clear to see why. Most of the children are born at home or in the cayuco on the way to the only island with a 'hospital' (which is a very minimal facility run by the MInistry of Health).

Here is the vision:
The Kapsars are willing to give that little building on Isla Bastimentos to become a clinic / hospital
If we can get 21 doctors/nurse practitioners we can staff the clinic/hospital the year around.
Each provider would spend two and half a weeks at a time on the island.
They would be able to live with the Kapsars in their house. (It is a great place with electricity and running water). However, they would pay for their room and board and bring along what medical supplies and equipment they can.
There would be a half week overlap between changing providers for a 'sign out'.
Contact between all members of this 'group practice' would be by email and if bandwidth on the island ever permits, video conferencing or at least pictures.
Once a year, we would all try to meet someone and discuss our 'practice'.
Each physician would return yearly.
There would be periodic visits from church supported mission teams that would help with constructions projects and mass medical camps, but our group practice would provide the continuity, follow-up and guide the incoming camps to identified areas of needs.
This vision would provide continuity of care, an established presence among the Ngobe and U.S. standard of care.
I am signing on as the first doctor. Any other takers?

The phone call

2009-10-11T20:46:00.002-05:00

New experiences don't end with residency. I love that about medicine. Another feature of medicine that makes it uncommon among professions is the human drama that goes with it.

I had seen a late 30-something for a complete physical last week. She looked down and through the course of the interview, I found out she had just finalised her divorce. To make matters worse, her 4 year old daughter had come away from her first visit with her father with bruises on her body. This brave woman fought back tears as she told me these things between looking in her eyes and ears. I felt a bit uncomfortable as a male provider doing this complete physical exam during a stage of her life when surely she must think all men are pigs.

Introducing the pelvic exam, as sensitively as I could, I offered her a complete sexually transmitted disease testing panel. At first she declined, but when I pointed out that in the context of the setting of the divorce, she might consider it, she agreed.

The results came back this morning.

I picked up the phone to call her. I pointed out that the Chlamydia test was positive. As if this was not bad enough news to give, I had to point out that as a notifiable disease, our lab had directly contacted the county healthy department. She asked if her name had been given. Honestly, I did not know, but I found out quickly. Not only was her name passed on, but a county health nurse would be contacting her.

Besides the devastation of getting a sexually transmitted disease from someone who had betrayed her in so many other ways as well, she was not concerned about her privacy and reputation. My heart was in knots as I tried to reassure her that even in a small town like ours, her information would be confidential. However, more and more people seemed involved in the loop: my medical assistant who receives the result from the lab, the lab personnel in charge of notification, the county health department and its share of employees that would be doing following up. I could see her point. I felt helpless and frustrated but that must be nothing compared to what she felt.

I'll follow her closely. I hope she's okay.

Aloepecia totalis

2009-10-04T19:27:00.002-05:00

It was a busy afternoon. The student working with me came out of the room and told me that next patient -- a 53 year old male was a caucasian male here for a physical. As busy as we were, I went into the room with her quickly. The patient had wanted us to see his 1 month old in the same visit and Mom came along as well, so there were quite a few people in the room. He took his cap off as I began my physical and I noted he was bald. I asked him when he lost his hair and he said when he was 39. I looked up at his face ready to begin the HEENT (Head, Eyes, Ears, Nose, Throat) part of my exam when I noticed, hello? He has no eyebrows. Wait! He also has no eyelashes and... no nose hair, no hair in his ears, no facial hair, no hair on his arms and legs. He smiled and said 'Aloepecia totalis'. Cool!

I have seen one such case before and it is in this blog. In that case however, it was the side-effect of a drug. In this case, it seems, the patient denied any exposure to that drug and any other for that matter. No-one else in his family has this.

Moral of the story: just when you think the physical exam is a routine...

Is the generalist a relic of the past?

2009-10-03T11:58:00.002-05:00

The other day I was talking to my brother. He told me casually in the course of conversation that he had got his physical for the year. He then mentioned that he had had his yearly appointment with the urologist to check his prostate. That got my attention. What's wrong? Nothing. He just sees a urologist once a year to check his prostate. He has no medical history of urinary or reproductive problems. He has never had urological surgery.

I was at a medical meeting and during a break talking with someone about how there isn't enough training in procedures during residency training. The person I was talking to turned out to be a subspecialist. He disagreed with me regarding training primary care doctors-to-be in procedures. He quoted papers that reported better outcomes when these procedures were performed by specialists.

So, should you go to a cardiologist to have a heart exam and evaluation? Should you see a nephrologist to manage your blood pressures? How about an endocrinologist or a diabetes specialist to manage your diabetes? Should a gynecologist manage your post-menopausal symptoms or a rheumatologist manage your osteoporosis or arthritis? Should you see psychiatrist for stress coping with changes in life or depression?

What is the role of the primary care provider? Is he or she to be a triage person, directing the flow of medical traffic to different specialist-destinations?

I am a primary care doctor. I don't treat a single organ or organ system. I don't wear blinders and only want to hear about your medical problems or complaints pertaining to just your heart or just your kidney or skin or mind or bones.

Are we emasculating primary care doctors when we deny them the right to be doctors and treat patients, rather than just refer them to specialists?

Of course, on the other side of the line is the recognition of the limitations of one's scope of practice. I won't do neurosurgery or try to remove your gall bladder or even do an angiogramon your heart. Some things are clear. But what about managing blood pressure in a diabetic, or abdominal pain in a pregnant, depressed young woman? Is that outside the scope of my practice? Who decides that? Me? The specialist? Some regulatory body? The public?

Of course, I have my own answers to these questions. And of course, as Einstein pointed out, the observer affects the observed phenomena. I am biased.

Fortunately, on a personal level, I am not legally limited in my scope of practice in any but the broadest ways.

Guilt

2009-10-03T11:41:00.002-05:00

Being a primary care doctor is a privilege in many ways. It is also a sacred position of trust. What is said in a doctor's office is, very few legal exceptions, never to leave the room. Of course, in the day of the electronic medical record, that is not entirely true, or is it? How much of what a patient tells you belongs in their medical record? Most would argue, effectively I think, that personal information divulged in the course of the encounter may not always belong in the record. Such information might be a personal event -- a child winning a ribbon at a competition, or a vacation story. The electronic medical record is accessed by numerous healthcare providers that care for a patient in the course of time. With the HITECH and HIPAA laws, accessing this information without a direct clinical context is a breach of law. However, what if a primary care provider records information divulged in conversation during the physical or during the office visit with their doctor? What if they record this information as part of the documentation?

Okay, this is a long preamble to what I really want to say in this piece. I have a couple of patients in my (young) practice that have varied medical complaints for which I have not been able to find an organic cause. I may add, it is not for want of looking. Healthcare dollars have been spent in procedures, tests and consults, all with no fruit. In both cases however, each patient has something they have done that they seem guilty about. They don't say they feel guilty. But their body language, the looking down, the averting the gaze, the downturning of the corners of their mouth, the sudden change of expression all say it.

There are numerous stories in literature about guilt affecting peopel in different ways, including symptoms of physical illness. Is this what is wrong here?

I have another patient who was abused as a child and is dealing with multiple phantom pains. I sometimes wonder if forgiveness is the 'cure' rather than the years of continued pain medications and periodic absences from work with physical therapy to achieve recovery.

I shall not leave myself out of this equation: I have guilt too. At the end of an exhausting day of planned and unplanned clinical encounters, phone calls, nurse notes, impromptu meetings with colleagues, residents, allied health providers and teaching, I am spent. I leave my office guiltily, leaving a desktop full of notes to be dictated, phone calls to be returned, requests from colleagues, students and residents for this or that -- things I am too tired to do. Did I do right by my patients that day? What about the one that left frustrated because I was running late and she couldn't wait anymore? Did I miss something? Did I miss the right decision in sending this one home? Should I not have admitted that one?

Guilt.

Is treating this root of medical problems within the scope of my practice? Should it be?

Discovering primary care...

2009-09-25T21:29:00.002-05:00

Why don't medical students want to go into primary care? Why do even primary care residents want to get out, taking routes such as fellowships, hospitalists positions, academics, even nonclinical jobs?

Perhaps it has to do with the student's experience of primary care. It is incomplete. It is a series of office visits with patients you may never see again. You get to make a diagnosis, fill out a follow-up medication and move on to the next patient, normally never seeing that patient again.

Well, I am in primary care. I think I am beginning to understand the joy of primary care.

Last week, I injected a painful hip (trochanteric bursitis), removed a small pebble from a child's nostril, aspirated a ganglion cyst, met a patient cheerful after beginning an anti-depressant, celebrated a new addition to the family of a little girl I have cared for since residency and got an 87 year old to walk again after I took fluid off his knee and injected it with steroids. Of course, the 87-year old was back the next with an even more swollen knee (he felt so good after the first fluid removal that he went home and got on his treadmill to catch up with exercise after all this time of being immobile).

They say that if you've suffered through a traumatic experience together, like fought in a war alongside someone or being involved in a life-or-death encounter, you form a special bond with that person. Well, bonds are being formed all over the place.

Last week, I was a dermatologist, a cardiologist, a nephrologist, an orthopedist, an endocrinologist and a psychiatrist, sometimes all in the same day. I love it!

Make hay while the sun shines...

2009-09-12T20:46:00.005-05:00

I love Peds acute care -- you never know what you're going to get (to borrow a phrase from Forest Gump).

There was an adolescent female in the room with her mother. Her ear had been feeling full and her hearing wasn't so good from that ear. With frustration, the mother and daughter mentioned that they had been seen 2-3 times now and it wasn't getting better. One diagnosis offered was swimmer's ear. The funny thing was that she had not been swimming. I asked her what she had been doing. Well, it was summer in Wisconsin and like many farm hands, she had been making hay all summer. I looked in the ear and saw something I had never seen before: it looks white and black and cottony. I got a sample and sent it to the lab, but I thought I knew what she had and gave her a prescription.

When we called her a couple of days later, she was feeling much better and almost back to normal. The lab studies confirmed the diagnosis: Aspergillus niger.

She had fungus growing in her ear. How might this have happened? During my exam, I noted that her hair was damp and there were pieces of hay stuck in. The damp, golden curls hung over the ear. I'm guessing the warm, damp weather of summer, the fungus in the hay she was making and the environment in her auditory canal probably created the "perfect storm" for the infection. Onychomycosis -- my first.

Paternalism, paternalistic and empathy

2009-09-12T20:27:00.004-05:00

I have several young woman in my practice. Well, I'm a Med-Peds doc so I have patients of all ages in my practice.

In the interaction between an adult and a child, paternalism seems quite natural. In medical school, we were warned against paternalism: defined in medical ethics as "A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities." Appropriately warned, physicians try to walk the fine line between the patient's "beneficience" and "autonomy".

When a 20-something young lady refused the HPV vaccine, tells me that she smokes while on birth control and has had at least 4 sexual partners in the past year, and does not use condoms every time, the 'father' in me wants to break out of the white coat and speak to her as I would if she were my child. After all, I internally reflect, from the perspective of the age difference between us, I could have had a daughter as old as her.

Lest you think there's something psychosexual about this, I feel the same way when my 20-something young man with Crohn's disease and a colectomy tells me one day before he is due to go to college that he has been having some abdominal pain and fatigue. The father in me once again wants to leap across the invisible waves to his cell phone as I'm trying to leave a message to him far away to tell him that his hemoglobin is low and he needs iron supplements and to see someone locally soon.

Okay! (deep breath).

These are adults (technically, at least), with their autonomy and I must not be paternalistic... I must not be paternalistic... I must not be paternalistic... I must...

What does your doctor mean to you?

2009-09-12T20:17:00.002-05:00

Dr. F came out of the patient's room to get me. It was a busy afternoon in the clinic and we were all in the middle of seeing our own patients. He wanted me to come and meet one of his patients.

Dr. F leaves our clinic in about a month. He is moving back to the coast to be closer to family. He has been here about 13 years. He did his residency here and is now the director of that same residency program. He is also the head of our department. As part of his last month's activities and in between trips to the coast to find a home, nail the job down and such, he is having to tell his patients that he can no longer be their doctor. He had spoken to me about this particular patient -- someone he wanted me to take over the care of after he left.

I entered the room to find a tearful, crying 50-something year old female. I asked her why she was crying and from her wheelchair she reached out to Dr. F and said, "I'm losing my best friend!"

I think both Dr. F and me fought to maintain composure in the presence of her emotional expression of what Dr. F meant to her. She held onto him for a few moments, tears flowing freely down her face.

This is what Dr. F meant to her. She told me that they shared a history together. He had told me earlier of her close encounters with death, debilitating disease and the march of chronic disease in her life through the years.

Over 13 years, relationships between doctors and their patients are forged in the therapeutic alliance for their health and wellbeing. This continuity, this partnership and ultimately, this friendship is what Dr. F and this patient have. This is primary care.

Biting your lip...

2009-09-03T21:18:00.003-05:00

Kind of getting into the swing of things: several days of seeing patients in my clinic, mornings of acute care in Peds, urgent care last evening. Interesting how one evolves after residency. When I see a patient, I'm sometimes torn between: did I work this up enough? Did I do too much testing? Should I have sent this one home or watched them in the hospital? Yesterday a 16 year old football player came in with a dislocated finger. I never set one of those in residency. I looked it up in a text and was all set to numb up the finger with a finger block. I got pre-reduction x-rays that confirmed the finger was dislocated. Then, I asked one of the other docs in urgent care that night -- a family physician with more years of experience if he had done one of these before. He came into the room with me and while talking to the boy yanked on his finger and set it. No pain medicine. He didn't think we should get post-xrays. I thought about the difference in comfort levels we bought had at different stages of our careers. I would have done it, but first numbed up the finger, then set it, then got post xrays, in short, spent more healthcare money and been more cautious. Some cases I think that if I was more experienced I would make the call with fewer tests. Other cases, I wonder if that is necessarily the right thing to do. Work in progress...

The Boards...

2009-08-29T18:13:00.002-05:00

Years ago, a physician told me "If you're going to be a doctor, I hope you love studying..."

Well, residency is over. The reading, of course, never ends... and neither should it. There are always new things to learn: new guidelines, new studies, new vaccines and new diseases. What many didn't count on though, was exams! Besides the inservice exams we do every year in residency (and in Med-Peds, because we are doing 2 specialties, we get to do two of these each year), there are the Boards.

After residency in Internal Medicine, graduating residents get to take the internal medicine board exams, held by the American Board of Internal Medicine. It is an all-day computer exam, going from 8:00 to 6:00 with 240 questions set in blocks of 2 hours each (60 questions to a block, so 2 minutes per question). If you pass this (pass rates have been of the order of 91 - 92% with roughly 7,100 taking it every year), you are certified as a diplomate of the Board of Internal Medicine -- a "board-certified" internist. This is the initial certification. One has to re-certify every 10 years. Sounds like fun, doesn't it?

It's amazing how there's a little cottage-industry that is spawned by the many exams in medicine. There are review courses, study guides, books, DVDs, CDs, MP3s... you name it.Every exam (the USMLEs, the Boards in each specialty) has its own little industry. While no-one can legally tell you what'll be on the boards, you hear a lot of "they're bound to ask you this, or that.

Well, I've been through yet another exam trauma -- the whole ritual of preparation angst, pre-exam anxiety, exhaustion and finally relief. I took the exam on Thursday this past week, so I 'blew off' this weekend (didn't do anything meaningful).

Results come in 3 months.

Oh, did I mention, that because I'm Med-Peds, I have the Pediatrics Board exam to look forward to. I plan to do that next year, but I'll start studying now. Fun, fun, fun!

The first day...er.. first 2 weeks

2009-08-16T21:17:00.002-05:00

I had meant to write about my first day in the job as a Med-Peds physician. That was July 27th. It is August 16th as I sit down to write this entry. The first day is a bit of blur, so I'll write about the first 2 weeks instead.

I remember that my first day had one no-show -- a bit anti-climactic. However, there were enough patients to keep me busy, mostly new patients who came to establish care. In these past 2 weeks, I have had a lot of adults coming into establish care and get an annual physical. Similarly, there have been a lot of kids who came for well-child visits and sports physicals. After the first 20 or so, I wanted to see a sick person! I enjoyed the freedom of seeing patients on my own. In the first couple of three visits, I would come out of the room, look for my staff, remember I was it and go back in to finish the visit. Even at the end of the second week, I still had to catch myself dictating "this is resident physician Vijay Aswani dictating..."

The first Peds clinic call was exciting. I was nervous about whether I would be able to keep up with the flow of patients. It was fun! I did end up admitting one 12 year old. My last case of the call morning was a little 2 year old with nursemaids elbow. I was able to click it back into place in seconds.The mother was suitably impressed. This is one of the few things in pediatric medicine where the fix is instantaneous. I was grateful for that case in my first day.

I staffed residents for the first time day before yesterday (the last day of my first 2 weeks). I supervized a resident tapping a left knee effusion that I had seen the day before and saved for this clinic. Everything went flawlessly. The patient felt no pain and we took off more fluid that I can remember taking off a knee.

All in all, I am feeling more at ease in my new job: building new patient relationships, taking care of patients and doing a variety of things with both adults and kids -- what a Med-Peds practice should be. Some highlights were: diagnosing my first case of diabetes mellitus type 2, tapping a knee effusion, setting a nursemaid's elbow, parotiditis, atrial fibrillation, managing blood med side-effectsd (hyperkalemia), performing a pelvic exam on a first time patient... the list goes on.

I have the internal Medicine board exams in about 11 days. Scary. Trying to study while practicing in these early days is hard: almost every patient is a new one that I need to get to know before I can go faster in my visits. Right now, each office visit is 30 minutes and each physical is an hour. I hear that that will change to 20 and 40 minutes respectively, within a month or so. Got to get faster.

My only beef is that I wish I had more time to think about some of the cases. If I could think, read and consider before having to 'move on to the next case', I would probably order fewer tests and maybe get to the answer faster in some cases and get to answer in some cases. Perhaps this will improve with time as I become faster.

Onward and forward to another week...

It's here...

2009-07-31T21:55:00.002-05:00

The time has finally come. Residency is over. The post-residency break is over. This Monday, August 3, 2009 will my first working day as a full-fledged physician... after all these years. This past week I was involved in orientation. Although I pretty much know my way around this clinic and hospital, having been a resident here itself, there were still things I needed to learn and being hired as a physician involves some different steps than being hired as a resident.

My fellow orientees were a young dentist fresh out of dental school, a family practice doc fresh out of residency, a research scientist moving to our Research Foundation from Houston, TX where he was faculty, a neurosurgeon, fresh out of fellowship training and a bariatric surgeon. Quite a bunch! It was fun to hang out with these guys who are in the same boat as me: starting their careers as physicians at the Marshfield Clinic.

During the week, I was also able to tour the faclities at the Med-Peds department where I'll be working. I have my own office, with my name on the door. I have my own medical assistant. Monday is a fairly busy first day with 4 patients in the morning and 4 in the afternoon. I know. It doesn't sound like much. But it will be the first time I am seeing a patient in clinic without having to staff it with an attending. I dictate the note under my own signature, not under the supervision of someone else. I don't have to say "seen, examined and discussed with Dr.---" like I'v e done for the past 4 years.

I'm excited and scared. Excited to begin. Scared because I don't want to miss anything. No more is there anyone looking over my shoulder, making sure I haven't missed anything or that I'm not barking up the wrong tree.

Of course, life is not fancy free. I have the Internal Medicine board exams coming up on August 27 and there's a LOT of studying to be done for that (and not enough time).

All told though, I'm looking forward to my real working day and week.

Camp Angel

2009-07-13T20:06:00.005-05:00

This weekend (Friday, July 10 to Sunday July 12, 2009), I was privileged to be at the Camp Angel summer camp. This is a summer camp run for children between the ages of 8 and 12 years old, that come from families touched by cancer. These kids have a sibling, parent or grandparent that has or has had cancer. The purpose of the camp is to provide them an opportunity to get away from all that 'heavy stuff' and hang out with kids who have experienced similar situations and just have fun.

The camp is one of several run by the non-profit organization Angel on my shoulder, formed by Lolly Rose (shown standing behind Mr. Chuck in the picture) after she lost her husband to cancer and saw the effect it had on her grandchild. You can learn more about this organization and its camps and other activities at http://www.angelonmyshoulder.org/.

I really enjoyed the experience. Ostensibly, I was asked if I would like to come and be the camp doctor. Jonathon Forncrook, my program director, had been going for the past 10 years and this was to be his last camp before he moves away to California. I had never been to a summer camp in the U.S. before and I was curious on several levels: how are summer camps run here? how are they different from back home? what kinds of medical care is involved at a camp? what makes a camp for kids with cancer in the family different from any other summer camp?

We left on a Friday morning and made the two and half hour drive up to Camp Luther in Three Lakes, WI. Once we arrived, it was only about half an hour before the bus bringing the campers -- 42 kids in all, would arrive. The groups were divided into 2 girl teams (the bunnies and the foxes) and two boys teams (wolves and bears). Each team had several counselors assigned to them. Each team stayed in a different camp -- the fort, the towers, the treehouse and pioneer city (wagons). Each of these camp sites were creatively constructed and looked like loads of fun.

We had a pizza party that night preceded by some icebreaking events. The Northern Lights Harley biking club came over with their bikes and allowed the kids to get pictures. The next day was spent mostly in water activities, with a ride on a pirate ship, run by the Strauss family in Eagle River, cayaking, fishing, swimming, tubing and such. There were crafts (face painting, rock painting, hair braiding and other such stuff) and a special DJ in th evening for a dance.

Medically, it was quite uneventful (thankfully): just the usual scrapes, bruises, some blocked ears after swimming and some sensitive stomachs. Homesickness was admirably managed by the counselors.

This was my first camp experience and I doubt it will be my last. I plan to go back next year. This organization also has a really crazy event called the polar plunge (read about it on their web site). I'm thinking of doing it!

The only sad event was that this was Jon Forncrook's last camp, after 10 years of service. From the sentiments he stirred up among the kids and volunteers, he will be missed.

Here it is...

2009-07-09T20:12:00.003-05:00

I got my residency completion certificate today. It is a grand thing, already framed. Here it is -- the testimony to 4 years of residency

Physician, heal thyself!

2009-07-09T13:31:00.004-05:00

It is a little over a week since my residency 'ended' (my last working day was July 1, but I am still a resident on the books until July 12). Last night was the first night that I think I slept right through. Strangely, during the nights before that, I kept waking up every couple of hours. My body seems to finally be making peace with the fact that I shall be sleeping most every night!

My days are spent studying for boards and ... well, I get ahead of myself.

Now that residency is over, I did an assessment of my lifestyle with the help of my brother with whom I had lively discussions on the matter during my family's visit for graduation. The results were not good: at a BMI of 28.1, I am overweight and with a resting pulse of 80, clearly not fit.

I guess it is time to make some life changes (since completing residency set that in motion). I have pledged myself to regular exercise, healthier eating and weight loss. I also made appointments with my doctor for a complete physical and the dentist for cleaning and treatment. Studying for the internal medicine boards (my occupation these days) has only re-inforced to me that I am overdue for these changes.

However, having recognized the problem and put a plan into place (and kept to it for the 1st 2 weeks now), I am hopefully on the way to a healthier me and to heeding the command of the old adage: physician, heal thyself!

Can't sleep

2009-07-02T02:17:00.003-05:00

Yesterday was my last day in residency. I was on call during that night so I came off at 6:00 am this morning. After attending a meeting and shopping for ingredients for breakfast, I came home. Since I hadn't slept in 30 hours (for the last time as a resident), my eyes drooped as I ate lunch and I went to sleep by about 3 pm.

So here I am. It's 2 am and I am now wide awake. Whaaa? Why can't I sleep? I am not on call. I am done. I have about 3 weeks off before I start my new job as an Attending in Med-Peds at the Clinic. I guess my sleep cycle is screwed up from the call. It'll sort itself out soon enough. It usually does.

Still.

It's 2 am in the morning and I can't sleep. I called the PICU and the Peds floor to get updates on the little girl I admitted last night. We don't know why see siezed, but she's better. Oh well, I guess that's what counts.

I know it's wierd that I called the hospital, but I can't sleep and I was curious. How wierd is that?

The last day of residency

2009-07-02T02:03:00.004-05:00

June 30, 2009: this was the last day of work in my residency in Med-Peds.

I began residency on July 13, 2005. Technically, that means I should work until July 12, 2009 to complete the four year program. However, I saved up some vacation time during my last time so that I could end on June 30. During the month of June, I was doing a rotation in Pediatric Hematology-Oncology.

Something special happened on this morning: as I drove into work, I saw a beautiful complete rainbow arc across the sky. It was a complete rainbow from horizon to horizon. One end of it dipped into the horizon just at the location of the Marshfield Clinic. Okay, I'm not going to read anything into this, but it was really cool and special, being my last day of residency and all. :-)

My last day began with Morning Report in Pediatrics. The ward team presented a case of a 4-year old with a rash and fever and we talked about rashes. It was nostalgic to be sitting there as a resident for the last time.

The morning was spent rounding on the 2 Heme-Onc patients we had. I then had an exit quiz in my attending's office. That went well. Interesting how one learns during these rotations. It's like when you look at yourself in a mirror everyday and can't see the changes accomulating daily. Someone else, seeing you after a period sees them immediately. The quiz gave me perspective on my learning in Heme-Onc.

After lunch, I sat down with the program coordinator and went through the exit list. A day before, I had got to hand over my resident's pager. However, since I am staying on here, it was simply replaced by an identical appearing but newer pager. Kind of an anti-climax: I had heard stories of people being so grateful to finally hand off the pager that had 'killed' many a night of sleep. Somehow, I never felt that way. Each page was an invitation to an adventure, a thrill.

Instead of the exit interview being a simple handing over of everything, it was more like a replacing of 'resident' stuff with 'attending' stuff.

The afternoon was not so busy. At 4:30 pm I went to the Pediatric ICU to get report on the patients I would care for during the night -- my last night on call as a resident. There were jokes about how after midnight, I might switch off my pager or simply tell the caller to page the 'resident' instead of me.

My last night on call was wonderful. I ordered pizza for everyone. Instead of wishing for a 'quiet' night, I actually wanted cases. My wish was granted. It was quite busy, with different, interesting admissions and call issues. I admitted a 20-month old female who had had 5 seizures that day. Her parents were both family practice docs. At 3 am in the morning, I did a spinal tap on her. My PICU attending made me a little plaque to wear on my back for the night that said 'After midnight, the bucks stops here!'.

It was poignant to spend my last day in residency on call. When I signed out at 6 am the next morning, I was officially done. The ward team to whom I had signed out were busy sorting out the admissions of the night. Since it was the start of a new month, it was a new team and you could tell they were a little nervous. Everyone had new roles: there was a fresh intern at the table -- his first day in residency; the second resident at the table was now a 'senior' resident -- he was an intern till yesterday, and the Ward Chief was starting his first day as a third and final year Peds resident and Chief Resident at the table. The PICU resident was busy gathering numbers in anticipation of morning rounds. Until yesterday, she too was an intern, and now she was a senior resident and the PICU resident for the month. And me, I was done.

I walked away from a busy floor of activity, everyone trying to step into their new roles, while attempting to provide continuity of care to our precious little patients. Life, as usual, goes on.

The retired physician

2009-06-25T16:49:00.003-05:00

I was in Wal-Mart the other day, when I saw a curious, elderly gentleman of East Indian descent looking at me. I smiled back. He asked me whether I worked at the Clinic and I said yes.

We started talking.

He had joined the clinic in 1967 and specialized as an anesthesiologist in doing cases in pediatrics and cardiothoracic surgery. Before long, he was reminiscing and talking about old cases. His wife spied us from across a few aisles and came up. She introduced herself.

It became clear that there was some element of senile dementia. From his wife's 'take-charge' attitude (she locked arms with him and began to lead him out where apparently, her sister had the car loaded with their purchases and waiting), it seemed like she was the primary caregiver. As she led/almost pushed him along, I could see the misty look in his eyes, as he was being led off almost mid-sentence....

Curious thing. We'll all get old and senile dementia increases with age. From the stories I heard, this was a successfull and trailblazing anesthesiologist with many 'firsts' in his career. Now he was a retiree who needed looking after.

This reminded me of a more tragic case: I was doing an emergency room rotation that month when the code pager went off early that morning. I ran behind the ER doc as we came to the ward floor. The patient was a retired physician who had come in for an elective prostrate procedure. In the early hours of the morning, his heart had stopped and when the nurses' aide came in to do vitals at about 6 am, he was pulseless with no respirations. We ran the code for about 30 minutes when it became increasingly clear that this frail but hitherto functioning individual was not coming back.

As the ER doc called his wife to give her the bad news, I reflected on the situation. I imagined that this physician had probably done CPR, and ran codes on others before, perhaps even some physicians. Here he was on the other end of that scenario, for the final time. A life spent in medicine and ended in a medical scenario.

As physicians, growing old, becoming senile, being on the receiving end of emergency medical care -- all this seems scary. And yet, it is our future.

Graduation week

2009-06-20T23:00:00.008-05:00

Every residency has a graduation day. Ours is called Residents & Fellows Recognition Evening. It was the 32nd one in the history of the Marshfield Clinic and Saint Joseph's Hospital. It was heald on Friday, June 12, 2009.

To attend this historic landmark event in the life of their loved one, my mother, brother, his wife and son came all the way from Panama. I was excited to have them. I took a week of vacation from June 6 to June 14 to host them here. We spent 5 days in Chicago and 2 in Marshfield. I guess, knowing how small Marshfield is, I thought they would enjoy Chicago more. It was a special time of togetherness, laughter, food and fun.

On June 11, my program director hosted a barbeque at his house in my honor. I was so embarrassed by the attention. Nevertheless, my family were touched by the honor. I received a Chief Resident award from him. My mother wept with joy and feeling. While I am embarrassed by attention and awards, I could not help but feel grateful for the recognition if it brought joy to mother's heart.

I truly believe that all our achievements are not ours alone. As one scientist said, we stand on the shoulders of giants. My family has supported me with much sacrifice and I am indebted to them.

A few weeks earlier, my bacteriophage research won me the Nikolai Award for the best Resident Research of the year.

At the 'graduation' evening, we had a great time. I was touched to see so many of our interns show up to support us on this evening. Belonging to the Med-Peds program, mine was the first name announced in the graduation. I picked up a white envelope to applause and returned to our table. I smiled when I saw what was inside: a red sheet of paper with "You may pick up your certification of completion on the last day of your residency" written on it. The ceremony is over, now get back to work :-)

The last event of the evening was an award given by the transitional year residents to a resident who has contributed the most to their medical education. I was pleasantly and genuinely surprised to win this award. I did not expect it, especially after all the glowing things that the resident said before she announced the winner's name. My family was once again proud and me embarrassed.

I am honestly happy that all the ceremony is over and I can get back to the work I enjoy so much in some measure of anonymity. In truth, when people are sick and hurting, awards seem a little crass. My 'award' is the saving of my patients. I pray for that award daily.

Then and Now...

2009-06-02T20:00:00.002-05:00

It's June, my final month of residency! Last night was my 4th last call of residency (not that I'm counting or anything...). Things have changed so much since my intern year: I used to have butterflies in my stomach on call nights -- anxious and afraid of what might come up and whether I'd be able to handle it. I was 'afraid' of admissions and codes. Like others on the floor in wards (nurses, aides, unit clerks) I would say "Don't say the 'Q' word (quiet) because we woouldn't want to 'jinx' it and get a lot of admissions, codes or pts in crisis. Now though, I look forward to call night to see what we'll get. I'm not afraid or anxious, although I maintain a healthy respect for the unknown in medicine.

At 3 am I got a call from a 3rd year resident who was on call in the CCU (Critical Care Unit). He had admitted an 80-something year old with severe hypotension. The patient was already on pressors through a peripheral IV and needed a central line. He wondered if I could come and assist. Sleep evaporated and I walked over with a bounce in my step. I was on call for Pediatrics but nothing was happening, so I looked forward to actually doing something that night.

During the first attempt at placing the line, the patient became unresponsive. We called a code, did chest compressions and got him back. The line was placed and an hour later I was back in Peds. In my intern days, this would have pumped me with adrenalin. Not so much last night. It was 'fun'. I know I need to guard against becoming complacent or over-confident. No one knows everything and these are literally life and death situations. But I feel ready for the next step in medicine. I am done with my training at the end of this month and looking forward to the future.

Foreign body (in more ways than one)

2009-05-30T11:08:00.005-05:00

This is a story from a little while back. We admitted a 17 year old female with abdominal pain. As part of the admission tests, we got an abdominal x-ray (a KUB). This is what it looked like:

When we saw the x-ray, we all wondered what those radio-opaque circular objects were. During morning rounds, we stood around the computer screen wondering if she might have inadvertently (or purposely) swallowed something, or were they foreign bodies or calcium crystals or pigments from a tatoo. Finally, since this was a patient I had admitted, I was elected to go into the room and ask her. As diplomatically as I could, I asked our little miss if there was something she might want to tell us. I told her I needed to examine her lower back. She dutifully turned onto her stomach and let me pull me the sheets down. I was all prepared to find a tatoo of some sort on her lower back skin but what I saw stopped me in my tracks and instantly provided the answer to our radiologic dilemma. I turned beet red as I saw a pretty pink thong with artificial gems studded in the pattern of a butterfuly on the triangular piece of thong. My colleagues all had a good laugh at me because I was obviously embarrassed by my finding. We all had an even bigger laugh when the radiologist's official read of the x-ray came back as:

"there are multiple radiopaque densities projected in the central aspect of the lower pelvis, probably at the rectosigmoid junction. I presume that this represents residua from suppository or previously-injected material."

Should we tell him?

Tortured thoughts....

2009-05-21T09:22:00.002-05:00

Perhaps my turn of thoughts is because I am still recovering in some form from a recent illness.

Still...

Last night, I sat at the nurses station on Peds trying to finish some paperwork. From down the hall, I heard the sound of a child wailing and crying. I could not bear it. I asked who this was and was told that this neurodevelopmentally delayed 11 year old cries unconsoleable like this every night. Incredulous, I walked determined down the corridor to see who this patient was and why she cried like this.

LW is 11 years old. She was born to a mother who drank during her pregnancy. After a period of failing to meet developmental milestones and some physical and mental signs of cerebral palsy, she was diagnosed as having a 'chromosome 8 inversion' abnormality and consequent severe cognitive impairment. In my years as a scientist, cheering excitedly and participating in the revolutionary sequencing of DNA and the human genome, I had never envisioned the face I saw last night. There is no way to fix a 'chromosome 8 inversion'. It occurs in every one of the billions of cell in this little girl's body. It is a life sentence. The ramifications and effects are not completely known. Few people have this.

Needless to say, LW is in a foster home. Not many individuals have the emotional and physical resources to care for such children. They are high risk for abuse and neglect. Sitting in her room, watching her wail and cry, frustration and anger burned within me. Why was she crying? How could I stop it? What was I missing?

Her nurse and me checked her daiper, repositioned her, tried to soothe her, turned the tv on and then off, turned the lights on then off, tried everything we could think of. No effect. I tried a mild sedative, then another -- no effect. The crying continued. I sat at her bedside, making eye contact, trying to look into the window of her soul, praying for insight, a connection, a solution. I can only imagine what parents and caregivers must go through, year after year, night after night. I searched the literature on sleep and behavior disorders among those with cerebral palsy and neurodegenerative disorders. I found lots of articles that talk about the toll it takes on caregivers, things tried and failed. I read her medical records and found that this problem had been going on for a while and several solutions were tried unsuccessfully.

This patient came to us with a horrible wound at the back of her head and neck. We are unsure what it is, how it got there and exactly how to make it better. At about 4 am in the morning, I thought I would try giving her something for pain. A little bit of morphine put her into much needed sleep! There was no aha moment. Maybe this was pain. Maybe she was exhausted. Maybe she was just done for the night. Who knows? But she slept.

What does the wailing and crying of someone with 'severe cognitive impairment' mean? Is it pain? Is it just the behavior of a disorganized and disregulated brain that cannot calm itself? The patient cannot communicate verbally and does not appear to follow verbal commands, so who knows? As I sat beside her trying to calm her and soothe her, I felt like I was listening to a scrambled brain cry out. In a dark moment of frustration and despair, I found myself thinking, " why do we prolong such a life? Are we really making any difference with what we do?" Dark, scary thoughts that come not from impatience with the patient, but from a mourning heart and mind that cannot think of an answer to make the suffering better.

We live to fight another day. It is morning again. I hear that she slept for a couple of hours and is up and quieted down... for now. My heart is still in knots. I hear the sound of a scrambled brain in a spastic body crying and I don't know what to do. I am driven to find answers. I love what I do. I am haunted by what I do. I want to be better, smarter, wiser.

Sickness

2009-05-21T09:12:00.002-05:00

It was Monday, the first day of the work week. I had feeling unwell all weekend and dragged myself into work Monday. After a busy clinic, I was feeling really run down. My nose dripped, my eyes were red and itchy and my body ached. As the night wore on, I found myself getting sicker. Fortunately, it is near the end of the academic year and the intern I was on call with was more than willing, and able to step up to the plate and field most of the calls. Still, as I lay on the couch in the residents' room feeling miserable and useless, I was overcome by guilt at leaving him alone to 'do it all'. I was afraid to go into the Pediatric ICU or the Oncology sections where our sickest patients with the most compromised immune systems lay, lest I infect them with whatever I had.

The next afternoon, after returning home, I felt I was getting worse. I agonized over the decision: should I go in to work or beg off sick. Healthcare workers are a strange breed. When we are sick, we feel guilt and dismay at not showing up for our patients and leaving our overworked and tired colleagues to take up the slack. And yet, who knows more the risks of exposing the sick to more sources of infection from the ones they come to for help and care?

I called in sick. I did present to the Urgent Care and was dutifully swabbed for swine flu, and the two common forms of seasonal flu. Fortunately, I was negative for all three. Fortified by this knowledge, I was able to return to work last night -- no runny nose, a minimum cough and a healing body. Perhaps one of the benefits of working with sickness is the constant exposure and 'education' our immune systems get, and the ability to consequently heal a little faster.

A colleague took my night of call. I shall have to 'pay her back' by taking her call in the future sometime. While I would not let such a good deed unnoticed or want her to gratuitously do my work, I do feel bad that our system does not allow for sickness. Maybe it does, but there is no equitable trade. I'm better and back on the other side of the sick bed, where I belong. By the way, those swabs hurt! OUCH! I guess I know how my patients feel when I order these tests...

A strange night of call in Pediatrics - Part 2

2009-05-02T13:32:00.002-05:00

We were only getting started.

We received a 6-month old little girl as a transfer from another hospital in a nearby town. While the story was not clear, apparently, her mother and 2 and 3 year old siblings were all dead of gunshots to the head. Her father sat dazed in their home, with the furnace running full and the vents shut off. There was a strong smell of gasoline and natural gas in the home as well as on the baby. Police rescued the little girl and seeing how she smelt of gas -- it came from her breath as well -- arranged for her transfer to us. The transferring physicians wanted her closer to access to a Pediatric ICU if she needed it. Ours is about 50 feet walking distance from our wards. A urine drug screen was positive for sedatives. The little girl was screaming, agitated and wouldn't take a bottle initially.

We activated the CAN (Child Abuse and Neglect) workup.

There was a lull from 1 am to 5 am (no admissions). At 5:45 am we received a little girl with a right eye swollen shut and some steristrips holding lacerated skin together at her right eyebrow. The family had had a picnic in the park the day before and encountered a dog without tags. He seemed friendly enough and came and sat under their picnic table. During the course of the picnic, the family made friends with the dog. Feeling sorry that no owner was in sight and no identifying tags were evident, they called the Humane Society to come and 'rescue' the homeless animal. A Society van was pulling up to the edge of the park. The little girl went to pet the dog goodbye and he bit her on the face, narrowly missing the eye but tearing open the skin of the eyebrow.

The rabies status of the dog is unknown. The girl became sick with a fever several hours later. A bite to the head from a dog of questionable rabies history, now showing signs of systemic illness, fever and increasing swelling and redness closing off the eye is cause for concern. I wrote admit orders and quickly examined the girl before rushing to make the 6:00 am signout to the incoming team.

What a night!

A strange night of call in Pediatrics - Part 1

2009-05-02T13:17:00.003-05:00

I was Ward Chief in Pediatrics Wards last month. That meant that I did not have any night or weekends call (I know, great, isn't it?). My last day on service, I switched call with a colleague who desperately needed the time off. What a night it would prove to be...

1. We had a young teenager on the service that had transferred out of the Pediatric ICU just that morning. She had been admitted for a suicide attempt (not her first). She had ingested some sedatives and ADHD meds and we were monitoring her for side-effects, with the intention to transfer her to a mental health facility in the morning. She had been 'chaptered' -- meaning that a sheriff's department had activated Chapter 51 of Wisconsin state law: detention against one's will for declaring intent to harm oneself or another. Towards evening, she became irritable, wanting to do things she was not allowed to -- these restrictions being part of a suicide watch. The 'sitter' (person who sits in the room and watches the patient who is on suicide precautions) called for help. The patient had tried to wrap the curtain in the room around her neck and shouted "I want to die!". Nursing responded. Apparently, the patient had a history of explosive rage disorder -- something we were not familiar with. Unfortunately, we were about to find out. She 'lost it' and began screaming at the top of her lungs. She attempted to leave the room. Her nurse attempted to restrain her physically and was bitten, hit and kicked. There was pandemonium. I rushed in.

Okay, time-out.

Medically, here's the situation. She had ingested an amphetamine and a benzodiazapine (to those of you to whom this means anything). We were monitoring for side-effects of the ingestion -- heart arrythmias, respiratory distress, altered mental status. I had to make a decision: am I going to give Haldol (drug that could cause or summated with the previously ingested meds, precipitate a life-threatening cardiac arrythmia) or not?

Back to the scene.

I added my weight (literally) to the bodies trying to physically restrain this large teenage (who weighed more than some of the adults in the room). I made my decision: I called for Haldol and repeated the dose three times, including adding a sedative as well. Since the patient had chewed off her IV, all these meds were given intramuscularly. The needles did not add to the patient's state.

Within minutes, the patient was quietly asleep. No cardiac arrhythmias, no respiratory depression. Just calm. Our nurse was sent to the ER for antibiotics. We were all rattled.

Peds is usually a lovely place to be: there is a little Winnie the Pooh forest, and pictures of doggies, brightly colored beach balls, flowers and toys painted on the walls. Most of our patients are cute, cuddly and make you smile.

Fearful and tearful, mom stood behind the scenes. Grandma stood next to her with fire in her eyes. There would be long conversations with them afterward.

Brain turns to mush

2009-04-11T07:27:00.003-05:00

The hardest part of Peds to me is when a child suffers an injury or gets a chronic disease that changes their lives forever. A permanent injury or chronic disease is a tragedy to anyone. The sad fact that it happens early in life makes it more tragic.

We have been caring for a previously functional, to most accounts, normal, 6-year old girl. Over the course of a few short weeks, she has transformed from a talkative 1st grader to a hemiplegic (one-sided paralysis), non-verbal body in a bed. Her eyes open and she grunts and cries when you approach her. She does not recognize her parents or grandparents.

What happened?

The truth: we don't know for sure. It has not been for lack of trying to find out. Last week, we went the final mile and did a brain biopsy -- understandably a last resort diagnostic. The neurosurgeon who performed the procedure reported dismally to the family that the consistency of the brain indicated breakdown and the sample he obtained may not have been sufficient.

After considering and rejecting multiple hypothesis, we now believe that this a form of post-influenza encephalitis -- a rare complication of the flu (which she had in early March).

It is our best guess that the changes that have occurred in this little girl are for the most part irreversible. I have no more to say in this case: the rest cannot be put in words.

Walking from room to room on a Pediatric floor in a hospital reminds me of that verse in the Bible: "Weep with those who weep and rejoice with those who rejoice."

Surfin' USA

2009-04-11T07:19:00.003-05:00

Well, I'm back in Pediatrics for the final 4 months of my training. On call this weekend, I learned something new about American culture: car surfing. The trauma code pager went off and announced a 'Level II Peds trauma'. Gathering information from the field reports on this soon-to-arrive patient to our ER, I overheard a dictation describing the 'car surfing accident'.

Car surfing: what's that. A nurse nearby smiled and told me that there was 'car surfing' and 'car skurfing'. Apparently, (according to this local authority, anyway) car surfing is when you stand on the roof of a car while someone else drives. You then put your hands out in the air (allegedly, to steady yourself) to 'surf' the wind. Skurfing is when you're on a skateboard and hold onto a bumper or some other part of a car while it drives.

Back to our trauma. A 17-year old female had climbed onto the roof of the car and getting ready to stand up on it and 'surf'. Unfortunately, her boyfriend started the car in motion a moment too soon to her and she 'wasn't quite ready' and fell off. 'Fortunately', the only injury she suffered was a nondisplaced skull fracture.

There you have it: surfin' USA.

Apology to Plastic Surgeons...

2009-03-22T18:02:00.002-05:00

I'm spending a couple of weeks rotating through plastic surgery. Okay, so you're wondering what a primary care doc is doing there? I want to hone my skills to perform office procedures and learn techniques that will help me when I do international medical work.

I confess: I felt a smug moral superiority to plastic surgeons. Sure, they make the big bucks, I believed, but they did so by taking medicine and turning it into a cosmetic shop to indulge the shallow whims and fancies of clients with money to burn. This is what I thought. I thought plastic surgery was all about tummy tucks, breasts (reduction, augmentation), nose jobs and such. And of course, it is about these things... but not all about them.

During the two weeks, I have seen reconstruction of wounds, repair of hand injuries, restoration of dignity and the crown of them all -- the repair of cleft lips. I apologize to plastic surgeons who are artists, creative surgeons and smart and skillful doctors who heal wounds and rebuild beauty and dignity.

In Memory of Miller Lite and other patients....

2009-02-20T17:44:00.003-06:00

Okay. HIPAA forbids me from using names. However, with a name as common as Miller or Smith, I think I may be safe.

During my last 2 months of back-to-back internal medicine wards, our team took care of a wonderful, witty, very sick 70-something male with the name Miller. Mr. Miller had suffered a massive heart attack several months ago that ended up with him getting bypass surgery. Although he pulled through the heart problems okay (sort of), he never really bounced back. By the time he came to us from the nursing home where he was (still) recuperating, he had developed fluids in both lungs and had lost so much weight, he appeared pale and cachectic. With the graveyard humor that hids the pain that is unavoidable as one watches life ebb and patients die, I nicknamed him Miller Lite.

Over the 8 weeks that we were on the wards, Miller Lite from "let's keep fighting" to "I want to die". Miller Lite always had something funny to say to you when you went into his room. He never sounded bitter, critical, frustrated, although sometimes he sounded sad. He had one living child, a daughter he had raised practically by himself. It was touching to go back and forth between daughter and father and hear the exact same admonition:

"Things don't look good, do they. Well, be easy on (insert 'dad' or 'daughter'). I don't want him (her) to suffer!"

I don't think I will ever forget Miller Lite. He died almost within days of being moved from the medicine ward of the hospital to the Palliative Care unit.

It reminds me of another patient that died. Ms Mindy was a 50-something female with cognitive delay with a moppy disposition who had endured multiple abdominal surgeries and wasn't recovering. I was a third year medical student and it was my first surgery rotation. I was married at the time and once wistfully remarked to my attending after countless days in the hospital:

"I think I know more about when Ms Mindy last passed gas or had a bowel movement than I know about how things are with my wife or my family." We both laughed and then there was the awkward silence that comes after a sad truism has been uttered.

Taking care of patients is emotional business (this clinical distance is a myth) and with the long hours and years of training of medicine, is it any surprise that a number of your emotive experiences and memories become those of your patients?

The psychologist who lost his mind

2009-02-20T17:35:00.003-06:00

I am spending the month in neurology. I got to spend a day working with a specialist in dementia. We saw a 73 year old male for a follow-up appointment. This gentleman was a Ph.D. psychologist by profession. It was moving to be a part of this encounter.

"Mr. J, I am sorry to inform you that I will not be able to support your application to the Department of Transportation to let you drive."

"That's... I can... why...."

Mr. J, I understand how frustrating this must be for you. You've probably had patients with Alzheimer's and might remember what this disease does..."

"I used to be.... I know! I... Alzheimer's... not fair..." and after a painful pause, 'frustating!

There is an irony in this encounter. The psychologist who measured the slipping away of memory is now in the 'driver's seat' of the very condition that will take him...literally... out of the driver's seat.

The IMGs

2009-02-06T14:16:00.003-06:00

IMG stands for International Medical Graduate. In the U.S. medical system, it used to identify a physician who went to medical school outside the United States. A subset of this group is sometimes identified as FMGs (Foreign Medical Graduate) -- to distinguish 'Americans' who studied outside the United States from foreign nationals who did their medical training elsewhere (often their home country) and who have come to the United States to pursue residency and perhaps fellowship training and perhaps to stay on and practice in the U.S.

I am an IMG. In the eyes of some, IMGs are viewed as somehow being inferior in their training and abilities to practice medicine in the U.S. As I finish residency training, I want to highlight a few of the IMGs I know...

Dr. RD is from Sri Lanka. He went to medical school in St. Petersburgh in the former Soviet Union. After completing his medical training, he returned to his country and pursued post-graduate training as a surgeon. He then served in their army as an Army Surgeon. He saw 'action' in the civil war. He subsequently came to the U.S., trained in Internal Medicine in New York state, and is now a board-certified Hospitalist.

Dr. MS studied medicine in her native India. She went on to do post-graduate training in Obstetrics and Gynecology and practiced as an OB/GYN for several years thereafter in India and the Caribbean. She came to the U.S. and started a residency in Pediatrics and is now a fellow in Pediatric Neurology in Boston.

Dr. NG is also from India. After completing medical school and post-graduate training in Dermatology and Venerology, he went to the United Kingdom. He practiced as a House Office there and became certified as a Member of the Royal College of Physicians. He is completing his residency training in Internal Medicine now.

Innumerable others trained in India, Palestine, Austria, Russia, the Ukraine, Sudan as physicians, surgeons, anesthesiologists, Internists, Cardiologists, Ophthalmologists and came to the States to train again, often in other specialties because their specialty would not accept but the rare IMG. Others have served in wars in Bosnia, Kosovo, Darfur and the Congo. Some have studied Russian, Serbian, German and French to be able to study medicine. A few have worked at gas stations and convenience stores while studying for U.S. board exams to get into residency training. Some have done Masters and Doctorates in Public Health, Microbiology and other subjects in order to have a visa to interview and study for entry boards before residency.

When you meet these physicians, you will not hear these stories. There is no sense of entitlement or pride or sacrifice. You will not hear about the number of times they have started from scratch, been discriminated against, been judged or slighted, often by those with much less training and experience than they have. You will only see them try to fit in and do right by their patients, bringing to the doctor-patient encounter a world (pun intended) of experience.

As I have rubbed shoulders with these physicians in training and learned from their cross-training, international exposure to medicine and marveled at their multi-lingual and multi-cultural sensitivity and competency, I cannot help but feel that once again, the United States is gaining the best. The shame and modest reticience I felt in identifying myself as an IMG when I began residency is gone now.

I am an IMG.

Announcing my babies to the world!

2009-02-05T20:36:00.004-06:00

Those of you who know me know I rant about bacteriophages. It has been a long four years of dreaming, many weekends and nights of labwork packed into the 'free' time of my residency, and here they are! These are two different species of bacteriophages isolated from the anterior nares of humans, being shown for the FIRST time ever! I believe no-one has ever reported the existence of these cute little fellows in the anterior nares of humans before. Of course, I shall be publishing soon.

Here they are infecting Staphylococci:

I told you I would find them. These are my babies and I am very proud of them. One day, little guys like these -- in some form -- will be the new antibiotics. Many thanks to all the great phage devotees out there who have helped...

Enjoy!

Morning Report Nostalgia

2009-02-05T20:17:00.003-06:00

It was 8:05 am and nursing a plastic cup of chocolate chai (a specialty of the Cattails Cafe in the lobby of the Marshfield Clinic) I was one of many bodies sitting in Conference Room G next to the cafetaria in St. Joe's.

The funny thing about the last year of residency is the nostalgia of some of our rituals. While I listened as the presenting senior resident teased up with the case of the day, I looked around the room...

I could see a 3rd year medical student reading out of his red Pocket Medicine -- the eager learner, probably overwhelmed. I remember those days... trying to drink all the water coming out of a fire hose and feeling the panic as gushes of the water of knowledge slipped past me.

Further down the line sat.. or rather snoozed a second year resident in scrubs... no doubt the resident on call the night before -- the night float. The post-call haze is still a familiar sedative to my mind and promises to meet me the day after my next call night and that comes soon enough.

Further down sit some of the third years: one of them is a good friend who is nearing the end of her pregnancy. Just looking at her face reminds me of all the experiences we have shared: nights of call, codes, inservice exams, morning reports, co-presenting at meetings. I shall miss her as she heads off to Nevada for the next year. She has taken a hospitalists job. She has a three year old at home, a second one on the way and a husband working in Vegas.

Around the corner of the horseshoe arrangement of the joined tables sits one of our attendings. He adds questions and reminds us of a couple more diagnoses we should add to our differential as we think through what our mystery patient might have. I remember how intimated I was by him my first year. Now, we joke around. I still admire him but he is more human to me now.

As my eyes round the table, fixing in turn upon each person present -- medical student, intern, second year, third year resident, attending, I cannot help but feel a comfortable sense of family. These are my comrades with whom I have served: nights on call, racing down steps toward a Dr. 6 code, standing in an ER bay examing a patient and sitting tired in the cafetaria wolfing down a quick meal as our pagers go off. A pager goes off. The CCU intern gets up and walks towards the phone at the back of the room, others making room for her.

This is my family and I am misty eyed as I think my days doing this are numbered...

Time Crunch...

2009-02-05T20:08:00.003-06:00

Sigh! It's been so long since I've written...
So much has happened...

Well, did I mention that with the beginning of my 4th year, I became the Chief Resident of my program?

During most of this year (academic year) I have agonized over:
1. Should I do a fellowship or look for a job?
2. Where is my place?

After soul-searching, I have abandoned my earlier plan to do an ID fellowship. Not to be arrogant, but with all the education I have, if nothing else, I should be able to learn outside of a structured curriculum. I love all of medicine, so I don't want to do a fellowship and narrow myself down to something. Perhaps what I will end up doing doesn't even come in a fellowship box.

Anyway, with that decision made, I began to look for jobs. I applied to mostly university programs and a couple of private clinics and hospitals with university affiliations. Although I have never dated, I get the feeling that these job hunting interviews were kind of like going out on first dates: everyone is formally dressed and showing off their best side and the whole event is somewhat orchestrated and pre-programmed.

I learned many things about the process and of course, myself in the process: promises are made that are not kept.

What I was looking for in my 'dream' job was the opportunity to:
1. Practice both medicine and pediatrics
2. Do so in an academic environment and,
3. Have the time, resources and opportunity to do research.
4. I was partial to places with existing infra-structure in international work since that is something I know that God has got for me in the future.

After travelling far and wide and having many fun experiences, I found my 'dream' job. It is right here at the Marshfield Clinic!

I am pleased to announce that come July 13 2009, I shall be the newest faculty member of the Marshfield Clinic Med-Peds department. Thank you, thank you.

I am setting up continued research collaboration with Sanjay Shukla's lab and my bacteriophage research. I shall look into getting an academic appointment from UW -- foundations for future research and teaching ventures.

The Suit

2008-08-23T23:31:00.003-05:00

Okay, first, I apologize that I haven't written any blog entries in here for a while. So much has happened and is happening...

When I applied to the Marshfield Clinic for residency way back in October-ish, 2005, I was so excited when I received an invitation to interview. I remember packing my little bag and taking a flight from Oklahoma City to Madison. I had already reserved a car to drive from Madison to Marshfield. It was to be a big adventure, as I arrived in the United States and spent my first several months in Oklahoma City. This was my first big trip outside the state, my first residency interview and my first 'road trip'.

When I arrived in Madison, I discovered to my horror that my bag did not make it. I had packed my new suit and dress shoes in there. With a sunken heart, I drove the 2 hours up to Marshfield and was promised that my bag would arrive later that evening and someone would bring it up. My interview was scheduled for 7:30 am the following morning.

To cut a long story short, the bag was finally delivered at 7:30 am the following morning. I had spent a sleepless night on the phone with various cities trying to locate the lost luggage and find a way to get it to Marshfield. I arrived late for my interview in a slightly crumpled suit (no time to iron it out) and red-eyed from a sleepless night.

Of course, as you know from reading my blog, I got the residency position here, despite these difficulties. However, I learned a lesson: always carry your suit with you on the plane.

Well, last Thursday, I was scheduled to attend an interview at my own institution for a job as an Internal Medicine hospitalist (a long story, for another blog entry). I had taken my suit (the same one I had worn to my residency interview) to the cleaners to have the pants let out a bit (okay, so I've gained a little weight in four years).

Schedules being as busy as they are these days (story of my life), I went to the cleaners at 7:30 am on the morning of the interview to collect the pants. There was some snafu and they had not returned from alteration! Deja vu.

I went to the interview in a slightly older suit, sucking my stomach in (pants even tighter than the other one). As I walked, belly sucked in, into the hospital for the interview, I could not help but think how every time I interview at this clinic, there is a suit story. Oh well, another lesson learned...

The interview went fine, by the way.

"...You will die in 3 to 9 months"

2008-04-27T20:05:00.003-05:00

I was taking care of a 66 year old female. She had survived cancer of the urethra (the tube through which urine exits the body). The radiation took its toll on her. It scarred her vagina, clitoris and urethral opening. She developed inflammation of a portion of her colon and had to have that portion removed. With all this, the lady that lay in the bed the morning I saw her was bright, cheerful and smiled almost apologetically for the embarrassment of her condition. What brought her to the hospital was not any of the above conditions I described-- she had weathered those and survived. Now she was leaking stool from her vulva. It was an incontinent leak she could not control. It was getting worse. The final in a succession of specialists to see her was a gynecological oncologist. On the phone later he told he had seen a lot of such cases before, having trained at one of the country's leading cancer centers.

His word in the patient's chart were direct and poignant: "This is a terminal condition. In my experience, life expectancy is usually 3 to 9 months." When I walked into the patient's room, she had already her the pronouncement from him. He had been her gynecologist for 15 years and cared enough to tell her the truth without the hemming and hawing less experienced or less caring physicians will indulge in out of their discomfort with the news.

There she lay. She looked at me with eyes reflecting fear, confusion, sadness and searching. Should she seek a second opinion? Did I agree with the assessment? As I gave her my opinion, she told me what an excellent doctor I was. She wasn't being facetious. She meant it. I didn't feel like patting myself on the back or accepting a compliment.

I left the room with respect and admiration for this wonderful woman who could accept news of an imminent death with such grace and fortitude -- much better, I will confess, than the 'excellent doctor'

"Give me some coffee!"

2008-04-06T21:32:00.002-05:00

69 year old Mr Jones (I'll call him) is in the medical ICU. He has lung injuries and breathing problems. He is NPO (nil per os -- which means 'nothing by mouth'). His son walked in this morning to see him, holding a cup of coffee in his hands, the aroma filling the room.

"Give me some coffee!" exclaims my patient slurring his speech and breathing hard. Mr. Jones alternates between being lucid and agitated and restless.

"Pa, the doctor said you can't have it." the daughter explains as she signals with her eyes for the son to leave the room with the coffee cup.

I overheard. I am 'the doctor'.

There is something that flinches inside whenever I am reminded that I have denied another human being the basic right to eat and drink by my 'orders' written in the patient's chart. I only have to write 'NPO' and sign my name. It is enough. The power.

Mr. Jones is NPO because he 'failed' the swallow test. When he was offered a little something by mouth in a controlled situation, he aspirated and choked on it. Perhaps he is still too weak, perhaps he suffered injury from the breathing tube that was in his windpipe for several days when he could no longer breath on his own. The NPO is medically justified and re-evaluated at regular intervals.

Still, I flinch.

When have you lived enough?

2008-04-06T21:16:00.003-05:00

During that same night, I admitted another nursing home patient for bruising and a history of repeated falls because of syncope -- losing consciousness. Further investigation revealed that he has a bad heart valve. He knew this and had declined repair or replacement of the valve. The poor heart function was causing kidney failure and now disturbing the electric conduction system of his heart. His heart was in danger of going into a fatal rhythm. He could die in his sleep or just walking down the hall, eating or using the bathroom. He was 79 years old and DNR/DNI. While he did not want to have the valve repaired or replaced (the cause of most of his life-threatening troubles), he was not averse to having a defebrillator put it -- a device that would 'shock' his heart back into a rhythm compatible with life if it went into a fatal rhythm.

I tried to explain to him that while this might 'solve' the problem of fainting spells and prevent him from dropping dead suddenly or dying in his sleep, it would do nothing for his failing valve, poor heart function and the resulting kidney damage. In fact, he would worsen and go into heart failure, resulting in fluid building up in his lungs over time and become progressively more short of breath and uncomfortable.

If I had this problem, I would much rather my heart go into a fatal rhythm and kill me instantly rather than my life trickle away with greater discomfort and diminishing quality. Furthermore, as my heart worsened, it would tend to flip into fatal rhythms more often, resulting in me being 'shocked' more often -- doesn't sound good. So my choices would be repair or replace the valve or nothing -- let me die whenever one of those fatal rhythms occur. After explaining this to the patient, he surprised me by saying that my logic sounded clear and that yes, he would like to have the valve replacement surgery.

I guess what surprised me is that this 79 year old gentleman living in a nursing home with no family close by, no wife and not much else wanted to live more and was willing to endure the surgery it would take to make that happen. And then I caught myself. Why was I surprised? I guess I kind of expected him to say that he was 'old' and had lived enough and that he would die someday somehow, so it this was to be way, then so be it. But no.

Of course, I respect his choices and will help him reach his goals, of medically possible. It is a subtle prejudice I need to watch for in myself: deciding when someone has lived enough and should 'throw in the towel'. Who makes that choice: the patient? the physician? the government (who will be paying for all of this in his case since he is on Medicare)? How do you make such a decision? By age? By quality of life? Who determines quality of life? Should we even offer him the surgery just because we can?

I guess we all have to think about the answers.

Who lives and who dies?

2008-04-06T21:08:00.002-05:00

I am back in Internal Medicine and on the Wards. The ward month is very busy with call every four days and walking up and down between the different floors of the hospital and the MICU. Still, I love it. Ward medicine gives you a 'captive' patient: he is in the bed and you 'control' his medicines, activity and diet. Compliance is hardly an issue.

My first call night of the month, I admitted -- at different times of the night -- two very similar patients. They both came from nursing homes. They were both DNR/DNI. They were both in respiratory distress and unresponsive. One seemed to have a urinary tract infection and the other dehydration and maybe a pneumonia. One was 87 years old and the other 82. With both patients, the management strategy was similar -- treat as sepsis with fluids and broad-spectrum antibiotics and that was what was done.

During the night, one of them died and the other not only lived but 'came to life' -- she woke up and began talking with us, quit lucidly I might add.

We often joke on the wards about 'let's go out there and save some lives!'. I am sure we have something to do with it, but sometimes I wonder how much...

One died and the other lived. We will still do what we do and maybe one day can stratify the risks better to predict the outcome. For now, I still believe God holds life and death in his hands.

She's got the look...

2008-03-26T20:40:00.002-05:00

I'm in Allergy this month. I am working with a wonderful Pediatric Allergist. As a resident in training, when you're in a specialty rotation like Allergy, things work a little differently. The Attending physician will send me in to the patient's room to see him or her first. I come out and 'present' the case to him and we then go in together and finish the encounter. During this second phase, I get to watch him interact with the parent and the child patient.

Something I've only noticed this month is the expression on the mom's faces as the doctor asks their child a question and their child answers.

There's the look.

The eyes light up, the face glows with warmth and pride and there's a playful smile on the lips as they almost try to mouth prompt the answers to the child. The roughest most confrontational adult is transformed when their attention switches from you to their child. The child, completely unaware, focuses on the doctor and answers the question. To me, the silent witness, the mom seems completely unaware of the expression on her face. The look.

A different patient room. A different child. A different mom. Ten, sometimes twenty times a day. Always, the same look.

Stories in Medicine: Poem: Waiting...

2008-03-26T11:23:00.000-05:00

Stories in Medicine: Poem: Waiting...

Who's the Adult?

2008-03-22T20:28:00.002-05:00

It's another night of call in the ICU. I've got to say that I do enjoy being on call for the ICU. Last night, I got called from the ER to admit a 35 year old female who had ingested an unknown quantity of (we think) tylenol. Her blood alcohol level was also sky high. She was stupurous and could not provide any information. Needing information on allergies, medications and other illnesses and hopefully some details on what happened, I asked,

"How did she get here?"

"The ambulance brought her."

"Who called the ambulance?"

"She did."

I looked to see how 'she' was.

'She' was a 12 year old frightened little girl, holding an Easter bunny under her arm.

Apparently, this family moved to Wisconsin from California. They lived in a trailer. Mom didn't have a job and dad worked as a lineman. The little girl tried to answer my questions but clearly, most of the answers were wrong (she thought the anti-depressants were blood pressure medicine). This frightened child saw her mom drink, then ingest a large number of pills, then become stupurous. When her mom wouldn't respond to her, she tried to call 911 on their cell phone. Since she couldn't get a signal, she went over to someone's house, asked permission to use the phone and called 911.

As she bravely tried to answer questions from the nurses, doctors and cops (suicide attempts always bring the cops), she didn't cry, act hysterical or break down. At the end of it all, she looked up at my with wide eyes and asked

"Is my mommy going to be alright?"

It was 1:30 in the morning. Mom was shipped off to my care in the ICU while a cop took the child to a foster home three towns away.

Imagine you are 12 and this is the evening you have had. Dad is nowhere. You are being taken by a policeman to a town far away from where you live at 2:00 in the morning to live with people you have never seen before. She didn't know it, but because of the suicidal intention, Mom would not be discharged from the hospital to home. She would be transferred directly an inpatient psych facility to work out the suicidal ideation. Of course, this was assuming she made it through the night.

As a Med/Peds doc, I see both adults and kids in my practice. Although in this case, the 'adult' was my patient, my heart cried out for the little girl.

Who's the adult in this situation?